A qualitative exploration of the parenting experiences of ex-military fathers diagnosed with post-traumatic stress disorder (PTSD)

ABSTRACT

The experience of post-traumatic stress has been implicated in adverse outcomes for trauma-exposed parents and their children. The aim of this qualitative study was to explore how ex-military service (veteran) fathers who had received a diagnosis of post-traumatic stress disorder (PTSD) experience and make sense of parenthood, their role as a father, and the parent-child relationship. Ten ex-military fathers from the UK who had been diagnosed with PTSD engaged in interviews which were analysed using Interpretative Phenomenological Analysis (IPA). The analysis resulted in four themes; ‘Not always being the father I want to be’, ‘Striving to protect’, ‘Developing insight and understanding’, and ‘Protective influence of children’. These themes captured participants’ experiences of the perceived negative impact of PTSD symptoms on parenting and an evolving view of the self as a parent in relation to this, taking action to protect children from distress and harm, the importance of developing insights and understanding both personally and within parent-child relationships, and the distracting and motivating influence of children and enjoyment of the parenting role despite the challenges experienced in the context of a PTSD diagnosis. Findings are discussed in relation to the extant literature, and clinical and research implications are outlined.

KEYWORDS:

• Parent
• father
• veteran
• trauma
• PTSD

Introduction

Many ex-military service members, or veterans as they are also known, will not experience mental health difficulties; however, research indicates that those who have served in the military report increased levels of anxiety, depression, alcohol misuse, and post-traumatic stress disorder (PTSD) in comparison to the general population (Rhead et al., 2022). A high percentage of ex-service personnel are also reported to have experienced multiple traumas including combat-related trauma and adverse childhood experiences (Murphy et al., 2019).

A recent study by Murphy et al. (2020) reported that 71% of a sample of treatment-seeking veterans met the criteria for a diagnosis of PTSD or complex PTSD. PTSD is a diagnosis characterized by ongoing difficulties related to re-experiencing, avoidance, arousal and reactivity, and mood and cognition, in response to experiencing a traumatic event (American Psychiatric Association, 2013). The experience of multiple or chronic stressors is associated with complex PTSD (CPTSD), a diagnosis characterized by the experience of symptoms related to PTSD as well as ‘disturbances in self-organisation’ namely affective dysregulation, negative self-concept, and disturbances in relationships (Maercker et al., 2013).

The severity and chronicity of the psychological and behavioural experiences associated with a PTSD diagnosis will vary between individuals. For some, this may include positive psychological change accompanied by new insights, a concept known as post-traumatic growth (Tedeschi & Calhoun, 2004). Nevertheless, the experience of flashbacks, feeling emotionally detached, hypervigilance, and irritability can have a significant detrimental impact on a person’s quality of life and relationships (Schnurr et al., 2009).

The cognitive-behavioural interpersonal theory of PTSD (C-BIT; Dekel & Monson, 2010) posits that there are three processes which maintain symptomology and negatively impact relationship functioning: behavioural avoidance and accommodation, cognitive processes and thematic content, and emotional disturbances. An example is that behavioural avoidance may have a deleterious impact on relationship satisfaction due to interfering with engagement in shared activities and with affective expression, impacting both physical and emotional closeness. Creech and Misca (2017) applied the C-BIT to parent-child relationships in military families and support for the bi-directional nature of the model was demonstrated; for example, it was noted that children may modify their own behaviour to accommodate, and in turn facilitate, avoidance symptoms, thus creating a circular reinforcing effect.

The effects of parental post-traumatic stress symptoms (PTSS) on children are well documented. In a review focused on military children, including adult children, predominantly negative outcomes were reported related to altered physiological stress responses, behavioural and conduct difficulties, and increased reporting of feeling anxious and depressed (Banneyer et al., 2017). Additional research reports a medium effect size of the association between parental PTSD and child PTSD-related symptoms (Morris et al., 2012), even when the offspring have not suffered the named traumatic event themselves, thus suggesting a transference of symptoms via the parent-child interaction. Proposed mechanisms of intergenerational transmission of trauma include silence, over-disclosure, identification, and re-enactment (Ancharoff et al., 1998). Additionally, theories of secondary or vicarious traumatization posit that as a child offers support by attempting to understand the experiences of the traumatized person, they may internalize these experiences and feelings, consequently developing their own trauma symptoms (Figley, 1986).

In light of these findings there has been growing interest in the impact and experience of a PTSD diagnosis on parenting. Post-traumatic stress symptoms (PTSS) experienced by ex-service members are associated with increased parenting stress, reduced confidence and satisfaction in the parenting role, poorer parent-child communication, reduced affective involvement, and reduced problem-solving (Christie et al., 2019; Creech & Misca, 2017), as well as the use of more inconsistent discipline, and reports of aggression directed towards children (Sherman et al., 2016).

In a recent systematic review, McGaw et al. (2019) drew together the extant qualitative literature exploring the experience of parental PTSD from the perspectives of veteran parents, their children, and partners. This yielded only 11 studies with themes relating to the fragility of the home environment, disconnection, but also the importance of family. Only two studies in this review explored the experiences of ex-service parents. These qualitative results described barriers to communicating with children about PTSD, the impact of specific PTSD symptoms clusters on parenting effectiveness, and the behavioural and emotional reactions of their children (Sherman et al., 2015, 2016). A more recent qualitative study by McGaw et al. (2018) exploring parenting and family life conducted in Australia also described experiences of disconnection, a sense of a pervasive impact of PTSD on family life, but despite this, a strong sense of family.

The experience of parenthood is complex and multifaceted. Research with ex-service parents indicates that being a parent increases the likelihood of receiving a diagnosis of PTSD (Janke-Stedronsky et al., 2016); however, parenthood has also been cited as a source of strength and motivation to engage in treatment (Evenson et al., 2008). Considering these findings together with the results of research highlighting both the intra- and interpersonal deleterious effects of post-traumatic stress symptoms, it is argued that it is important to further understand the experience of ex-service parents diagnosed with PTSD.

Furthermore, much of the research in this area to date has used quantitative methodologies with mixed samples of active and ex-service parents. It has been argued that the needs and experiences of ex-service personnel are likely to be different given that they have navigated the transition to civilian life and no longer have the same structures and supports in place as those still serving (Creech & Misca, 2017). The existing qualitative literature is scant and has focused on communication about PTSD, the impact of symptoms, and family life more generally (McGaw et al., 2018; Sherman et al., 2015, 2016). To date there has been no research conducted in this area with former members of the UK armed forces.

The previous qualitative studies in this area, as cited above, have included a mixed participant group of both ex-service mothers and fathers, but it has been documented that experiences of parenting, as well as the narratives surrounding the parental role, can be different for each parent (Yaffe, 2020). As such, it is argued that there is utility in further exploring the experiences of each group in depth. The majority of ex-service personnel are male, though the number of females joining the military and subsequently assuming veteran status is growing (Ministry of Defence, 2019). In addition, available literature indicates that fathers have been underrepresented in parenting and family health research to date (Leach et al., 2019). The overarching aim of this research, therefore, was to gain an in-depth understanding of how ex-service fathers who had received a diagnosis of post-traumatic stress disorder (PTSD) experience and make sense of parenthood, their role as a father, and the parent-child relationship.

Method

Design

Semi-structured interviews were used to gather data in this qualitative study which utilized Interpretative Phenomenological Analysis (IPA). IPA recognizes a ‘double hermeneutic’ as the researcher interprets the participant making sense of their own lived experience (Smith et al., 2009).

Participants

A purposive sampling strategy was used to recruit participants from a group of treatment-seeking veterans who had received support from a national charity which offers support for veterans experiencing complex mental health problems. A total of 10 participants were recruited in line with the inclusion and exclusion criteria outlined in Table 1.

Table 1. Study participation inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
Aged 18+ No longer serving in the military. Identifies as a father / guardian to biological and / or non-biological child / children of any age. Currently have regular contact with their child / children. Received a diagnosis / met diagnostic cut off for PTSD. English speaking.	Individuals who have children but no longer have contact with them of any kind. Individuals who had sustained a brain injury that resulted in neurological damage that significantly impaired their memory and / or concentration. Individuals who were experiencing active psychosis or were actively suicidal.

Participant demographics are outlined in Table 2. All participants had previously met the criteria for a diagnosis of PTSD during their initial assessment with the charity using the PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013), and had engaged with the charity for support with symptoms of PTSD during 2019. All participants were male; nine identified as white British, and one identified as white European, though discussed growing up in the UK. Participants ranged in age from 40 to 68 (M = 56.9 years) and their children’s ages ranged from 3 to 48 (M = 25.25 years). No limits were specified on the age of the child as it is recognised that the parenting role continues beyond childhood (Holt et al., 2020). With regards to their time in the military, this ranged from 9 to 25 years (M = 19 years), and the time since leaving the military ranged from 5 to 42 years (M = 20.4 years).

Table 2. Participant demographics.

Pseudonym	Age bracket	Armed force served in	Marital status	Child and contact information	International Trauma Questionnaire interpretation
Ben	40–44	Army	Separated	Son & daughter (<18 years old) Stay every other weekend	CPTSD
Oliver	40–44	Army	Married	Two daughters (<18) Live at home	Scores did not meet diagnostic cut offs
Adam	45–49	Navy	Divorced	Two daughters (one <18 and one >18) Sees when he can, regular phone calls/messages	Scores did not meet diagnostic cut offs
Jason	50–54	Air Force	Divorced	Son (<18) Stays each weekend	CPTSD
Richard	55–59	Army	Married	Daughter (>18) Sees once per month plus regular calls and messages	CPTSD
Shaun	60–64	Air Force	Cohabiting	Daughter (>18) Sees every couple of weeks plus regular calls and messages	CPTSD
Chris	65–69	Navy	Married	Son & daughter (>18) Sees weekly plus regular calls and messages	CPTSD
Jonathan	65–69	Army	Married	Daughter (>18) Visits regularly plus regular calls and texts	PTSD
Keith	65–69	Army	Married	Two sons & two daughters (>18) Sees every few months plus regular calls and messages	CPTSD
Tim	65–69	Army	Married	Three sons & one daughter (>18) Youngest son lives at home, no contact with eldest son, regular contact with middle children	CPTSD

Materials

Trauma experiences measure

Prior to the interview, participants completed the International Trauma Questionnaire (ITQ; Cloitre et al., 2018). The ITQ is an 18-item self-report measure, which has been validated with community and UK veteran samples (Murphy et al., 2020), and assesses PTSD and CPTSD symptoms. If an individual met the criteria for a diagnosis of CPTSD, specified by the endorsement of items reflecting ‘disturbances in self-organisation’ as well as endorsement of items related to symptoms of re-experiencing, avoidance, sense of threat, and functional impairment, then they would not also receive a diagnosis of PTSD.

As aforementioned, all participants had received a diagnosis of PTSD during their assessment following initial contact with the charity. The ITQ was used as a measure of current mental health status when participants were recruited into the study. As all participants had previously met the criteria for PTSD diagnosis they were not excluded based on their ITQ scores.

Interview schedule

An interview schedule was developed keeping in mind the aims of the study whilst also remaining consistent with IPA methodology. The schedule was informed by reading relevant literature and consulting with the research team as well as four veterans who worked for or were associated with the charity through which participants were recruited. Topics and questions to include in the interview schedule were initially discussed with the veterans consulting on the study, prior to a draft being developed. Feedback was invited on this draft and changes in terminology were made in response to this. As well as this, the consulting team discussed their views of the acceptability of the research generally, and they highlighted the importance of building a rapport with the participants given the potentially sensitive nature of the interviews.

Procedure

Ethical approval for the project was granted by the Salomons Institute Research Ethics Panel. An email was composed and sent via the charity’s research team to 200 veterans who had previously taken part in a study exploring the health and well-being of veterans and had given consent to be contacted about future research. Interested individuals contacted the lead researcher (MS), and following receipt of an information sheet, those eligible and willing to take part also completed a consent form. Sixteen individuals initially expressed an interest in participating; four individuals did not respond to initial correspondence, and two individuals planned to meet with the researcher but later withdrew citing deterioration in their mental health.

One member of the research team (MS) met with participants on two separate occasions via Zoom (n = 9) or telephone (n = 1). The ITQ (Cloitre et al., 2018) was completed and demographic information was collected during the first meeting. Participants engaged in semi-structured interviews (range 35–100 min, M = 76 min) during the second meeting. These were recorded using a Dictaphone and transcribed verbatim by the lead researcher (MS), with personal or identifiable information removed or changed. The audio files, anonymised transcripts, as well as demographic information and ITQ questionnaires, were stored on a password-protected storage device.

Data analysis

Transcripts were analysed by the lead researcher (MS) according to the analytical process in IPA outlined by Smith et al. (2009) and Smith and Nizza (2021) who discuss updated terminology which is used here. Each transcript was analysed individually before moving onto the next. Transcripts were initially read twice, whilst also listening to part of the recording to recall the participant’s voice, to support familiarization with the data. Exploratory notes were made noting descriptive, linguistic, and conceptual comments. These notes were used to inform experiential statements which offered a concise summary of the experiences of the participant throughout the transcript, and these statements were then grouped together into personal experiential themes. Patterns and idiosyncrasies across the personal experiential themes for all participants were explored and collated, resulting in group experiential themes and subthemes. Analysis was iterative in that transcripts were repeatedly reviewed throughout the process.

Quality assurance and reflexivity

Principles that guide high-quality qualitative research outlined by Yardley (2000) were followed throughout. Sensitivity to context was achieved via reading relevant existing literature, consulting with veterans about the design of the study, and remaining mindful of ethical considerations. Furthermore, reflexivity was supported by the lead researcher (MS) engaging in a bracketing interview with the research team prior to conducting the first interview and a research diary was kept throughout. The bracketing interview allowed space for the lead researcher (MS) to reflect on and bring to awareness their own assumptions, biases, motivations, and expectations (Alase, 2017). These included assumptions that parenting was both a positive and challenging role, that those in the military may be exposed to more ‘masculine’ narratives which may hinder their ability to talk about their emotions, and that trauma can have devastating impacts but can also result in growth in some people. These personal responses are informed by the researcher’s positioning as a white British female trainee clinical psychologist who professionally has worked with individuals who have experienced trauma, and personally as someone who is not yet a parent, but whose father served in the Royal Air Force. Additionally, at the time of undertaking this project, the researcher’s partner was in the process of transitioning out of the military.

Methodological rigour was achieved by following the guidelines for the analytical process in IPA (Smith et al., 2009; Smith & Nizza, 2021). Annotated transcripts and themes were also shared with the research team. Furthermore, experiential themes were continually compared with the transcripts to ensure that they were grounded in the data.

Results

Analysis of all interview transcripts resulted in the development of four group experiential themes and 9 subthemes.

Not always being the dad I want to be

This group experiential theme captures how participants made sense of themselves as parents in the context of PTSD symptoms negatively impacting parenting. There is an emphasis on the word ‘always’ in the title of the group experiential theme; this reflects the participants’ evolving view of themselves as parents, as well as their experiences of reconciling the challenges of being a parent diagnosed with PTSD, feelings of guilt, and a sense that they are doing / have done a good enough job as a dad.

Disconnected and disrupted parenting

This subtheme encapsulates how parenting was negatively affected by the psychological and behavioural manifestations of PTSD. For some participants low mood was experienced as most challenging, whereas for others it was irritability and heightened arousal. Keith and Tim were the only participants to describe engaging in verbal and threatened physical aggression directed towards their children. These reactions appeared to be understood in the context of emotional ‘outbursts’ related to PTSD, but also in relation to parenting during the 1980s when physically punishing children was more commonplace.

All participants spoke about the variable nature of PTSD, and there was a consensus that parenting felt manageable if mood and behaviour remained relatively consistent and ‘under control’ (Richard), whereas experiencing a deterioration in mood or behaviour appeared to be overwhelming and present more challenges:

Yeah when I’m on a downer I’m more shouty, I’m a bit more shouty with them. Then when I’m in a good mood I’m more cuddly so it’s like … yeah …  (Ben)

All participants described feeling disconnected at some point from their role as a father and from their children. The sense made of this varied between participants. Seven participants described becoming avoidant and withdrawn, resulting in physical and emotional detachment. This was described as having a detrimental impact both on the participants themselves as well as their children, with a sense that opportunities for showing love and affection, as well as spending time together, was lost for both parties:

You know they started to miss out or I started to miss out because I wouldn’t socialise or I didn’t want to socialise. (Oliver)

Um, I think I lost the love for them. And because I wasn't giving them the love that I'd given before, it wasn't reciprocal, they weren't giving me the love. (Chris)

Participants also seemed to feel disempowered as a result of PTSD which resulted in a change to or loss of their usual role as a father:

They knew that I was dad and I was in charge. But when I had the breakdown obviously [wife’s name] took over the kids. So she was looking after them and she was making the decisions with the children. They all look to her mainly now. (Tim)

For Adam and Shaun, two participants who described experiences on operational tours in which they witnessed the deaths of children, reminders of these traumas encountered during parenting and subsequent avoidance and re-experiencing impacted their ability to be physically present:

I don’t know how long I sat there staring to be honest and I don’t know how I come round and then saw that it was her again, but I wasn’t- I physically wasn’t sat in my front room holding my daughter, I was physically in a compound holding a dead child. (Adam)

Shaun: I thought it must be because it was a child involved in my PTSD and then I had a child the bloody same sex, you know. And it was just, you know I think if I’d have had a son it wouldn’t have been as bad.

I:

Why do you think that is?

Shaun:

Well because it wouldn’t be reminding me of the little girl.

There was a sense that the trauma was ‘alive’ for Shaun due to it being difficult to separate his daughter, and therefore his role as a father, from his trauma experiences; something that was distressing for him.

I haven’t fulfilled my parental duties

In discussing and reflecting on their experiences of being a parent, nine participants described feeling guilty about their behaviour. The use of the word guilt by most participants suggested a feeling of unhappiness and regret linked to thinking that they had done something wrong, caused harm, or had compromised their own standards of who and what a father should be: ‘I feel like I haven’t fulfilled my parental duties, I’ve let her down’ (Adam). As part of this there was a sense that children were an innocent party who did not deserve to suffer as a result of having a father diagnosed with PTSD:

It’s like a punishment for them as well which isn’t fair; I did what I did, I volunteered, I joined up in my job. It’s not their job, it wasn’t their choice. (Shaun)

The experience of guilt was painful for the participants, with these difficult feelings considered as another challenge to deal with on top of PTSD, and further compounding existing low mood or critical perceptions of themselves:

So that guilt then makes things worse in a way, because you haven’t been as playful as you’ve wanted to be or as you normally are … so you have those thoughts to deal with. (Ben)

Oh it’s horrible that is. Makes me feel even more depressed that does, yeah. (Tim)

For many participants the burden of guilt pervaded, even when children and others shared their reassurances, indicating that these feelings had perhaps become ingrained over time:

Some people might see me as a good dad anyway, but it’s in my head, I’ll never be good enough. If you never think you’re not good enough there’ll always be … that’ll always play a part I suppose. (Ben)

They’re [his children’s] response was what I actually anticipated. But er … I still punish myself for it’. (Keith)

Maybe I am a good enough dad?

Over the course of the interviews eight of the participants began to acknowledge shared enjoyment with their children, beliefs that their children saw them as reliable or generally ‘alright’, and their own perceptions of doing a good job as a father. An example is articulated by Tim who initially commented ‘I don’t regard myself as a good parent at all’ and moved to a place where he was able to recognize doing some things right: ‘My son did tell me a few weeks ago that he loved me so [laughs] … yeah so he- there must be some right there’ (Tim).

It is of note that these discussions occurred towards the end of the interviews. This may have been related to many of the participants’ tendencies to keep things hidden and to just carry on, as discussed in the next theme ‘striving to protect’. It is hypothesized that engaging in the interviews perhaps gave the participants space and permission to take a step back and think about their experiences more holistically. Acknowledging the positives and attempting to reconcile that it was ‘not all bad’ seemed to also have a positive impact on how participants felt about themselves:

I want to take a bit of the praise and I feel as though I have done something towards it, not as much as the wife, but it takes two of us to model the kids. So yeah I've got it right. I have. That makes me feel better, I was starting to feel quite down actually, but no, I'm feeling ok. (Chris)

Striving to protect

This group experiential theme encapsulates the conscious effort made by participants to change and moderate their behaviour in response to an awareness and understanding of the potential detrimental impact of their traumatic experiences on their children and their relationships. Within this, participants described engaging in behaviours that appeared to serve the function of not only trying to protect their children from distress and harm, but also of preserving their children’s positive view of them as a father.

Shielding children from the realities of distress

This subtheme encompasses the actions taken by participants to hide their mental health difficulties. Only one participant explicitly described engaging in behaviours that shieled children from the realities of distress in order to protect them:

I think that you become quite a good liar if I’m honest. I think you become very apt at acting and being able to cover things up quite well. And that's a really sad thing to say, but you do it, I done it to protect my girls. (Oliver)

However, descriptions by other participants in relation to being aware of the concept of intergenerational transmission of trauma, a conscious awareness of children’s perceptions, and not wanting their own behaviours to affect their children, suggested that hiding parts of the self served a protective function. Four participants described assuming a mask or ‘acting’ to hide true feelings:

It’s a mask really. It’s more of putting a mask on to say, ‘everything’s great, there’s no problem here’, so he doesn’t really get to see it. (Jason)

Similarly, Tim described developing a ‘skill’ in making sure that his son was protected from his mental health difficulties:

We’ve always kept things away, not got him involved with things to do with my mental health and all that lot you know. I suppose it was a skill we developed. (Tim)

These descriptions appeared to emphasize the conscious effort involved in keeping up appearances, with some participants acknowledging that this was exhausting and not possible to continually maintain.

As well as being motivated to protect their children from the ill-effects of trauma, for some participants, hiding difficulties was due to a fear that the parent-child relationship would be negatively affected if children, including adult children, experienced the truth:

I really do not want to lumber her with this because she’s her own woman, she’s got her own things to think about and this shouldn’t really affect her and shouldn’t affect her relationship with me, and I’m frightened that it would. (Chris)

The use of the word lumber here suggested that Chris may experience himself as a heavy burden, one not to placed on someone else, especially his child. Not being seen as weak was also important for some participants, potentially highlighting the influences of norms and narratives surrounding the concept of masculinity:

Thing is, my daughter will go ‘well my dad was this hard man’ – this is my fear – ‘this hard bloke, this tough man and that, and he couldn’t face a problem, and his way out was topping himself … so I’ve got a problem I’m not big and tough so how am I going to deal with it?’ (Shaun)

A fear of being judged negatively was also experienced by other participants. There seemed to be an understanding that being judged by your own children is particularly painful, and that perhaps it is safer to be more open and honest with ‘strangers’ not connected to the family, such as professionals:

Sometimes it’s easier talking to a stranger than it is actually talking to someone you know, because … I don’t know whether it’s the judging thing? (Adam)

I can’t let anything happen to them

This subtheme relates to the more explicit forms of protective behaviour engaged in by participants to ensure safety, such as not letting their children do certain things, being ‘on guard’, and ensuring preparedness:

When you take them out on day trips and places like that, um, there’s always that level of heightened awareness when you’re out and about with them … a level of protection and preparation that goes into it … going somewhere. (Ben)

Heightened awareness and hypervigilance were also described by other participants, highlighting the increased sensitivity of the participants to their environment and awareness of potential threats. This constant scanning seemed to add an additional layer to the role of dad to that of ‘protector’, with Shaun drawing parallels with being ‘like a bodyguard’ to his daughter.

For Adam and Shaun, the need to protect their daughters appeared to be impacted not only by potential unknown threats but also by previous experiences on operational tours in which they witnessed, and were unable to prevent, the deaths of children:

Because I think … I feel like … I definitely lost people in Afghan, but I feel like I lost people that didn’t need to be lost in Afghan, and a lot of mine orientates around children. There are different scenarios with regards to children dying and you know that little girl definitely sits with me because we wouldn’t have hit the compound if it wasn’t for the target pack. (Adam)

The little girl sitting with him suggests that Adam has retained an awareness of a time when he felt that he should have protected a child but was unable to. His later discussion of ‘I even went and bought her a tracker’ (Adam) suggested that he was taking control of what he could do to protect his daughter.

The good intentions behind wanting to protect their children from harm were recognized by participants, perhaps aligning them with any other caring and attentive father. However, good intentions appeared to be quickly outweighed by the extreme nature of the behaviours which became overwhelming for both the participants and their children:

I daren’t sleep at night in case anyone came in the room. How ridiculous was that? So I went for days not sleeping which made me worse, you know grumpy, sleep deprivation, it was killing me, and just ruined everything for everyone really. (Shaun)

Developing insight and understanding

This group experiential theme relates to how insight and understanding is developed and navigated within relationships. Participants highlighted a need to understand themselves, with five participants describing feeling confused and unaware of the extent of their difficulties in the aftermath of trauma pre-diagnosis. The reciprocal nature of understanding was also discussed, with participants wanting to reassure their children whilst simultaneously acknowledging the importance of feeling understood and accepted by their children and families.

Understanding supports connection

Developing understanding seemed to support interpersonal connection with others, as well as intrapersonal connection, i.e. making sense of the self in relation to previous experiences:

My therapist gave me a book and for me that probably was a really good book to make me understand my PTSD and to understand what it was all about … it’s really interesting … before I didn’t understand what was wrong with me. (Oliver)

Many of the participants also shared detailed accounts of their combat experiences during the interviews. This was interpreted as participants feeling that perhaps the author did not have enough of an understanding and the details were required to gain some insight into what the men had been through and the unique experience of warfare:

I find civilians- sorry to be insulting to a civilian, civilians have a very peculiar view of what warfare is like and what it’s like to be under fire and to shoot back; like I say, it’s both terrifying and amazingly exciting at the same time. (Richard)

This demarcation between combat veteran and civilian was likely acutely experienced in the parent-child relationship, and feelings of frustration around misunderstanding, or concerns about admitting feelings of terror, an admission not aligned with the hegemonic masculinity commonly associated with the military, may have precluded the men from talking to their children about their experiences.

However, partners and children developing an understanding of participants’ military experiences and responses to trauma was seen as helpful and supported participants with feeling validated and less alone:

They've always been loving and caring and everything, but now I think they saw what I was going through … and they've got a good understanding of it. And not so much the respect is there, but the loyalty, the love, and understanding is there. (Chris)

As well as feeling understood themselves, it was important for some participants to reassure their children what had happened / was happening was not their fault:

I want to at some point in time put that across to her which I tried to say you know reinforce that fact that nothing you’ve done has caused any of the situations that we’re in at this present moment in time. (Adam)

Four participants cited the role of professional intervention in supporting the development of new insights, which in turn prompted more open discussions with their families:

It [therapy] shows you the change and perceptions. I don’t try to be that rufty-tufty soldier anymore to my girls and/or to my wife, because I think without talking, you know it's really difficult. (Oliver)

Oliver highlighted how the role he assumed in the military, one characterized by being ‘rough and tough’, had spilled over into his role as a father. However, with therapeutic support there had been shift away from this role to an awareness that talking and showing more vulnerability supported building connection with his family.

For Ben and Richard, a change in perspective had occurred in response to experiencing combat trauma and subsequent mental health difficulties. The experience of trauma seemed to highlight the fragility of life and not taking life itself or relationships for granted, with these insights facilitating a deeper love for their children:

I think it matters now because I’ve seen how valuable it [life] is. So has it affected my relationship with my daughter? Yes, but because I think I love her properly. (Richard)

An awareness that mental health difficulties were / are experienced in response to trauma also seemed to promote empathy and curiosity with children:

When I’m dealing with the children and their behaviour I often think what’s going on behind that in their head? So what’s the reason for it and … Because of my own experiences with mental health, there’s a reason behind it you know, it doesn’t just happen, something’s going on. (Ben)

How do I explain? (If I want to explain)

This subtheme captures the complexities of explaining experiences to facilitate understanding. Participants referred to the level of explanation being dependent on their children’s ages, with young children requiring much less explanation than older children. Some participants felt able to offer a basic explanation to their children, and some were happy to avoid the conversation altogether. For the participants who did want to explain their experiences, responses, and offer reassurances, there was an uncertainty and lack of confidence which appeared to hold them back:

All my life I’ve had to say to my daughter one day you’ll understand, which you know, wasn’t good enough really. (Shaun)

Five participants seemed to experience a dilemma with regards to whether or not they should explain what was going on. Here, the recognition that supporting children to understand could be helpful was balanced with a fear of getting it wrong or making it worse:

I think that can be quite a scary sort of thought about where you go [with explaining] because you know is that helpful or not helpful? Will that have an impact or not have an impact? I don’t know really, it’s not the easiest thing in the world really to go with. (Adam)

Protective influence of children

This group experiential theme describes the ways in which the participants experienced their children as providing a significant and valued source of enjoyment and support in their lives. For many participants, their children and the parent-child relationship provided support, distraction, comfort, and a way of coping with difficulties even when other relationships and activities could not.

Keeping going for them

This subtheme captures the experience of children playing an active and significant role in the participants’ well-being. This was spoken about by eight participants. For participants with younger children in particular, children were seen as a welcome distraction. As well as distracting from difficulties, all participants experienced their children as a motivating force:

I don’t see him the same as everyone else; he’s my son, he’s my family, he’s the family for me … he’s everything, my son’s the reason, you know. (Jason)

Within this, there was a recognition that the needs of the child took precedence over the participants’ own needs and a sense of ‘doing it for them’. Chris and Ben both discussed this in relation to their motivations to seek and continue with treatment:

I’ve sought treatments, help with it, because I want to be … the whole reason is to keep a relationship with my kids, that’s why I engage with [the charity] was because I want to get better and be a better dad for them, that’s the whole reason behind it. (Ben)

You know, if it's affecting my family and the tablets stop it affecting my family and my friends, let's do it, you know, I'll keep taking it. (Chris)

Further descriptions of trying to be selfless indicated that this was at times an effortful endeavour on the part of the participants: ‘I’m fighting on for my daughter and my granddaughter’s sake’ (Shaun). The use of the word ‘fighting’ here appeared to highlight the intensity of this, and perhaps also drew parallels between parenting whilst living with PTSD and military experiences of contending in combat. Despite these challenges, the effort of being selfless seemed to have benefits for both the participant and their children:

And yeah it’s just trying to be selfless, and I have to put them first over me, and not in a negative way, because I think it’s a positive thing because actually I end up benefiting from it anyway, so it ends up being fine. (Oliver)

Furthermore, five participants described how their children had saved them, with the presence of children and the importance of the father-child relationship appearing to play a significant role in protecting against the overwhelming experience of symptoms and suicidal ideation: ‘Yeah … if it wasn’t for them I might not be here’ (Keith).

The joy of fatherhood

Five participants described the general pleasure and happiness they experienced in their role as fathers. These verbal descriptions were accompanied by visible indications of their experience during the video calls; for example, participants smiling and laughing. Two participants focused on the positive impact of the transition to fatherhood. For Ben, positive change as a result of becoming a father seemed particularly pertinent as his son was born at time when he was finding it difficult to cope with his diagnosis of PTSD:

And then we started a family together and then my son came along and that was a massive change for the positive for me, that was brilliant you know, that was amazing. (Ben)

Other participants with older children spoke of the development of a special bond over time which has been maintained and is valued:

Oh yeah, you know I always look forward to seeing her, always look forward to seeing her. And it makes me feel good when I see her as well. And you know it’s- You see it’s a source of pleasure, it is, I mean I get pleasure out of talking about her. (Jonathan)

For all participants contributing to this subtheme there was a description of the joy of fatherhood remaining constant, despite this at times being overshadowed by the challenges of parenting in the context of PTSD: ‘But god they’re good fun. That’s the thing isn’t it, I really enjoy being a dad’ (Oliver).

Discussion

The aim of this study was to explore how ex-service fathers who had received a diagnosis of post-traumatic stress disorder (PTSD) experience and make sense of parenting. The theme ‘not always being the father I want to be’ captured participants’ experiences of how PTSD symptomology influenced and impeded their parenting. Participants described the impact of low mood, irritability, avoidance, and re-living trauma on their ability to engage with their children physically and emotionally. These findings resonate with previous research identifying symptoms characteristic of PTSD significantly negatively impacting on parenting in veteran populations (Cohen et al., 2011).

In their qualitative study, McGaw et al. (2018) described participants’ experiences of ‘disconnectedness’, something that was also reported in this study as participants described feeling emotionally detached and avoidant. This mirrors previous quantitative literature in which numbing and avoidance symptoms were associated with decreased perceived parent-child relationship quality (Ruscio et al., 2002). Additionally, the impact of intrusive traumatic memories on disconnection was noted by a small number of the participants in this study.

In reflecting on their experiences of parenting, the majority of participants described feeling guilty, which was experienced as an additional challenge to manage on top of PTSD. To the author’s knowledge this is the first study to describe feelings of guilt in relation to parenting in a sample of ex-service fathers with PTSD. Participants’ critical perceptions of themselves as fathers can be understood in the context of research suggesting that trauma can threaten the view of the self, thus contributing to negative self-appraisals (Brown et al., 2016). Towards the end of the interviews there was a shift in some participants being able to recognize their strengths as fathers, which in turn was noted to have a positive impact on the participants mood.

Participants’ experiences of taking action to protect their children and the view of themselves as fathers within the parent-child relationship were captured in the theme ‘striving to protect’. An awareness of the potential detrimental impact of PTSD on children and an understanding that trauma can be ‘transmitted’, ideas that have received significant attention in the literature (Ancharoff et al., 1998), appeared to underlie this. Furthermore, the role of hypervigilance can be understood within the C-BIT model (Dekel & Monson, 2010), which posits that attentional bias towards threat is thought to influence concerns about loved ones’ safety, which in turn prompts behavioural reactions to ward off anticipated threat. Additionally, references to maintaining the ‘tough bloke’ persona and not showing weakness indicated the influence of societal narratives regarding men being strong and fathers as providers and protectors (Miller, 2011). These constructions of masculinity may have also been reinforced in the male-dominated military environment in which characteristics such as strength and courage are privileged (Eichler, 2017).

The importance of understanding the self as well as shared understanding with children and families was highlighted in the theme ‘developing insight and understanding’. Many ex-service personnel can feel isolated in their experiences, with this isolation exacerbated by the experience of stigma and self-stigma, for example, internalizing perceptions that individuals with PTSD are ‘crazy’ (Mittal et al., 2013). In this study, feeling understood, accepted, and supported by their children and families was important to participants and when present, helped to facilitate connection with them. The role of family support and involvement is well documented, and is associated with decreased symptom severity and improved engagement with treatment in veterans diagnosed with PTSD (Wilcox, 2010). For some participants insights gained through engaging with treatment prompted more open discussions with their children and families which helped to facilitate understanding. For others, in line with the concept of post-traumatic growth (Tedeschi & Calhoun, 2004), new perspectives had been gained as a result of traumatic experiences which facilitated increased empathy and closeness with their children.

Some participants described experiencing a dilemma about explaining their difficulties to their children. These findings are in line with previous research investigating the challenges and complexities of ex-service parent and child communication about PTSD. Sherman et al. (2015) reported barriers to communication including concerns that children will not understand, fears that children will become distressed, and ex-service members not knowing enough about PTSD themselves. Supporting parents to navigate these dilemmas and barriers may be particularly pertinent considering research which suggests that silence contributes to the intergenerational transmission of trauma as children sense discord but struggle to process this (Ancharoff et al., 1998).

Previous studies have described how children provide practical and emotional support to ex-service parents with PTSD (Sherman et al., 2016). However, within the theme of ‘protective influence of children’, it was the presence of children rather than them ‘doing’ things per se, which appeared to distract from distress and motivated participants to engage in treatment and generally ‘keep going’ even when this felt challenging. These findings concur with previous research recognizing the role that having a child can play in motivating positive change in fathers experiencing mental health difficulties (Evenson et al., 2008). Furthermore, in contrast to previous research reporting an association between PTSD and decreased parenting satisfaction (Samper et al., 2004), half of the participants described the happiness and pleasure they experienced as fathers, despite the challenges outlined. It is of note that the study conducted by Samper et al. (2004) was a quantitative study, and the differing findings may in part be due to the qualitative nature of this study elucidating the nuance of the men’s experience. Additionally, it is acknowledged that engaging in treatment may have offered the men opportunities for further self-reflection and supported reconciling both the challenges and joys of parenthood.

Limitations

In line with guidelines for conducting research using IPA attempts were made to recruit a homogenous sample. The group were closely defined in terms of several characteristics such as gender, being fathers, ex-military status, and PTSD diagnosis; however, it is recognized that there were vast differences in the ages of the participants and the age of their children. Though all had regular contact with their children, it is acknowledged that the experiences of caring for younger children who live in the family home at least some of the time may have been very different to participants who had older children living more independent lives. Within this, there is a recognition that some participants may have relied on more retrospective reporting.

Additionally, individuals experiencing active psychosis and / or suicidal ideation were excluded from taking part in this study, as determined by the charity’s inclusion and exclusion criteria for treatment. Research reports associations between traumatic life events and psychosis and suicidal ideation (Glenn et al., 2020; Kozarić-Kovačić & Borovečki, 2005), and as such, the experiences of these could be considered a response to trauma. A limitation, therefore, is that the views of veterans experiencing more acute levels of trauma-related distress may have been excluded.

Though it is acknowledged that some individuals find receiving a mental health diagnosis helpful, illness models of distress and associated diagnostic categories, i.e. PTSD, have been criticized for being reductionist and pathologizing, with reported considerable cross-over of ‘symptoms’ between categories questioning the validity of discrete diagnoses (Allsopp et al., 2019). PTSD symptoms are only one way of conceptualizing trauma related distress, and as such, it is recognized that by focusing on PTSD diagnosis only, the study may have excluded the views of veteran fathers experiencing other responses to trauma, both in terms of distress but also positive psychological changes such a post-traumatic growth.

A further limitation of this study is that only treatment-seeking veterans were included. Research indicates that severity of PTSD as well as factors such as concerns about stigma and emotional readiness for treatment (Ross et al., 2018; Stecker et al., 2013) can be barriers to veterans engaging in support. As such, it may have been that the voices of those with more complex presentations were not heard in this study, and perhaps the men in this sample were more open to talking about and reflecting on their experiences as parents, though this cannot be stated conclusively.

The response rate to the initial recruitment email was low; however, it is not clear how many recipients were parents so the number of eligible potential participants cannot be estimated. The potential for selection bias is nevertheless acknowledged. Anecdotally, all participants discussed feeling motivated to engage in the research to help others and to enhance understanding and support for military families in which a parent has a diagnosis of PTSD.

IPA does not seek to generalize from results; however, given that all participants in this study identified as White British and in/were in heterosexual relationships, the sample was likely not representative and may not reflect the views of minoritized groups.

The double hermeneutic inherent in IPA research means that the findings presented here are the result of the author making sense of the participant making sense of their experiences, and as such alternative interpretations may be reported by a different researcher. Though steps were undertaken to make conscious the researcher's motivation and biases, it is acknowledged that development of the research and interpretations would have been somewhat influenced by the researcher’s experiences and beliefs.

Clinical implications

The findings of this study highlighted the centrality of the parenting role for veterans diagnosed with PTSD. As such, when accessing services, it is recommended that individuals are screened for parent status at initial contact. Current National Institute for Health and Care Excellence (NICE) guidelines recommend individual interventions for the treatment of PTSD (NICE, 2018); however, the reported significance of self and others’ understanding indicated that including children and families in treatment provision may be beneficial. This may take the form of joint sessions between ex-service members and their families or adjunctive sessions for families and children, with the expanding literature in this area documenting the benefits of these approaches (Jones & Lucero, 2017).

A recent study by McGaw and Reupert (2022) exploring adolescent children’s experiences of parental PTSD in ex-service families reported one superordinate theme of adolescent children of veterans ‘growing in silence’ which encompassed experiences of no one in the family talking about parental mental health difficulties, despite children being aware that something was wrong. The adolescents interviewed in the study by McGaw and Reupert (2022) also described interpersonal and emotional disconnection and avoidance, a finding aligned with experiences of emotional and physical detachment and withdrawal described in the present study’s subtheme of ‘disrupted and disconnected parenting’. These findings taken together suggest the need for services, if offering family or parent-child interventions, to support building parent-child connection more generally prior to focussing on parental PTSD. In line with this, it seems important for clinicians to acknowledge and validate that initial conversations about parental PSTD may be difficult, particularly if this is something families have not discussed previously. Initially, work may involve meeting with the ex-service parent and their child(ren) / families separately to discuss expectations and sharing of information. Additionally, services signposting children and families to age-appropriate information about PTSD may be helpful in the first instance, with psychoeducation perhaps offering a place to begin discussions between parents and children.

Despite the challenges mentioned above in the study by McGaw and Reupert (2022), the adolescents interviewed also described how they saw their parents as role models and as people who are strong and resilient. These strengths may be harder to see for some ex-service fathers, with those in this current study describing feelings of guilt and as though they have let their children down, with many also describing a tussle between reconciling being a ‘good’ father whilst living with a diagnosis of PTSD. As such, it may be helpful for clinicians to support drawing out unique outcomes highlighting strengths in the parent-child relationship, or parental behaviour, to support the development of an alternative, less problem-saturated narrative.

Though all participants described experiencing combat-related trauma, traumas involving children appeared particularly significant for some participants, with parenting influenced by intrusive memories and avoiding trauma-related triggers involving children. As such, it may be beneficial for clinicians to remain curious about the impact of traumas involving children for ex-service parents.

Research implications

Given that mothers and fathers often assume differential parenting roles and practices (Yaffe, 2020), it is recommended that further qualitative research be conducted exploring the parenting experiences of ex-service mothers diagnosed with PTSD. Additionally, understanding more about the experiences of ex-service parents from minoritized ethnic backgrounds and those from the LGBTQ+ community would also enhance the literature in this area.

This study included participants with children with a wide range of ages. It is acknowledged that the demands of parenting are likely to be very different at varying developmental milestones. As such, further research could explore the experiences of more specific groups of parents, for example, those who are parents to babies and young children, adolescents, and adult children.

The literature focused on child experiences of parental PTSD in ex-service families is growing (see McGaw et al., 2019 for a review), with available qualitative literature reporting the retrospective experiences of adult children (McCormack & Devine, 2016; McCormack & Sly, 2013) and, more recently, adolescent children (McGaw & Reupert, 2022). As noted above, there appear to be both similarities and differences between the experiences of ex-service parents and children in relation parental of PTSD. However, as research in this area is currently in its infancy further qualitative research with ex-service parent-child dyads may contribute to enhancing the understanding of similarities and differences between how PTSD is experienced within the parent-child relationship, particularly given the suggested influence of attentional bias towards threat and the negative impact of trauma on perceptions of the self and others in ex-service parents with PTSD (Brown et al., 2016).

Conclusions

This study explored how ex-military fathers diagnosed with PTSD experience and make sense of parenting and the parent-child relationship. Ten interviews were undertaken which were analysed using IPA. The analysis resulted in four themes and 9 subthemes relating to the perceived impact of PTSD symptoms on parenting and an evolving perception of the self as a parent in relation to this, a need to protect children from distress and harm, the importance of developing insights and understanding, and the protective influence of children on well-being. The use of more systemically informed interventions may support ex-military fathers and their families in developing understanding and connection. Further research exploring the experiences of ex-military mothers as well as children could further enhance the understanding of the experience of a parent’s diagnosis of PTSD in ex-military families.

Acknowledgements

Thank you to the men who participated in this study and who so generously shared their experiences. The authors would also like to thank the staff at the charity who supported with disseminating the initial recruitment email.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research was undertaken as part of MS's clinical psychology doctoral training.