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Psychology of Violence The Role of Marital Adjustment in Suicidal Ideation Among Former Prisoners of War and Their Wives: A Longitudinal Dyadic Study Gadi Zerach, Yossi Levi-Belz, Menucha Michelson, and Zahava Solomon Online First Publication, March 13, 2017. http://dx.doi.org/10.1037/vio0000093

CITATION Zerach, G., Levi-Belz, Y., Michelson, M., & Solomon, Z. (2017, March 13). The Role of Marital Adjustment in Suicidal Ideation Among Former Prisoners of War and Their Wives: A Longitudinal Dyadic Study. Psychology of Violence. Advance online publication. http://dx.doi.org/10.1037/vio0000093

Psychology of Violence 2017, Vol. 7, No. 1, 000

© 2017 American Psychological Association 2152-0828/17/$12.00 http://dx.doi.org/10.1037/vio0000093

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The Role of Marital Adjustment in Suicidal Ideation Among Former Prisoners of War and Their Wives: A Longitudinal Dyadic Study Gadi Zerach

Yossi Levi-Belz

Ariel University

Ruppin Academic Center

Menucha Michelson

Zahava Solomon

Ariel University

Tel Aviv University and I-Core Research Center for Mass Trauma, Tel-Aviv, Israel

Objective: Posttraumatic stress symptoms (PTSS) are implicated in high suicidality and low levels of marital quality among traumatized veterans and their wives. However, the role of marital quality in suicidal ideation (SI) of war veterans and their spouses remains relatively unexplored. The current study examined the longitudinal associations between marital adjustment and SI among ex-prisoners of war (ex-POWs) and their wives. Method: Through opportunistic data collection, a sample of 233 Israeli couples (142 ex-POW couples and a comparison group of 91 veteran couples) were assessed at 2 time points: Time 1 (T1; 2003) and Time 2 (T2; 2008), 30 and 35 years after the 1973 Yom Kippur War. Participants completed self-report measures of PTSS, depression, dyadic adjustment, and SI. Results: Among both husbands and wives, higher levels of marital adjustment were related to lower levels of SI. Surprisingly, an actor-partner interdependence modeling analysis revealed that for both ex-POW and control groups, husband’s marital adjustment moderated the contribution of his PTSS to his SI, while controlling for prior SI in T1. Moreover, only for control couples did the husbands’ marital adjustment moderate the wives’ PTSS contribution to the husbands’ SI. Conclusions: Ex-POWs’ and their wives’ marital adjustment are longitudinally related to their SI. Improving couples’ marital adjustment may buffer the detrimental implications that both partners’ PTSS bears for veterans’ SI. Keywords: captivity, suicidal ideation, PTSS, prisoners of war, marital adjustment

graphic and psychological factors (Nock et al., 2008), as well as the SI rates among war-related trauma survivors, a more thorough understanding of the factors associated with SI is of major importance. Moreover, it is important to consider studies that include multidimensional and longitudinal designs to explore SI among individuals at risk as well as their significant others—for example, their wives. Thus, in the present study, we aim to prospectively explore the role of couples’ perceptions of marital adjustment as a factor that may contribute to SI among ex-POWs and their wives. War captivity is considered a unique and highly severe form of war-related trauma. During captivity, most prisoners of war are held in poor conditions and continuously deprived of food, water, and sleep. Some POWs are also subjected to brutal torture, interrogations, humiliation, and violence. Mock executions are often carried out and the use of solitary confinement is pervasive. Deprivation of benevolent human interaction enhances the captive’s dependency upon his captors. The lack of social support, denial of privacy, and continuous torture and humiliation may cripple one’s self-identity and potentially pave the way for a breakdown of the defensive mental health system (Herman, 1992; Rintamaki, Weaver, Elbaum, Klama, & Miskevics, 2009). Consequently, high rates of posttraumatic stress disorder (PTSD), ranging from 16% to 88%, have been observed in exPOWs (e.g., Rintamaki et al., 2009). Although PTSD has been recognized as the most common disorder for traumatized individuals, it does not take into account the complicated and enduring

Suicidality occurs along a continuum ranging from suicidal ideations (SIs), to making a suicide plan, to carrying out a suicide attempt, leading to a completed suicide (Bush et al., 2013). One prominent predictor of completed suicides is SI (Suominen et al., 2004), which entails the presence of current thoughts and plans to commit suicide. A considerable body of research has documented the close association between war-related trauma and an increased risk of SI (e.g., Jakupcak et al., 2009). For example, recently O’Toole, Orreal-Scarborough, Johnston, Catts, and Outram (2015) found that among Australian Vietnam veterans, the prevalence of lifetime SI was 24%, with a relative risk of SI being 7.9 times higher than the general population. Considering the significance of SI in the prediction of suicide attempts, above and beyond demo-

Gadi Zerach, Department of Behavioral Sciences, Ariel University; Yossi Levi-Belz, Department of Behavioral Sciences, Ruppin Academic Center; Menucha Michelson, Department of Behavioral Sciences, Ariel University; Zahava Solomon, Bob Shapell School of Social Work, Tel Aviv University, and I-Core Research Center for Mass Trauma, Tel-Aviv, Israel. This study was supported by a research grant for the understanding of suicide phenomena on the name of Doron Assaf. Correspondence concerning this article should be addressed to Gadi Zerach, Department of Behavioral Sciences, Ariel University, P.O. Box 3, Ariel 40700, Israel. E-mail: [email protected] 1

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symptomatology associated with exposure to prolonged and repeated traumas, such as war captivity (e.g., Ford & Kidd, 1998). Indeed, studies by our team have found that ex-POWs reported higher levels of continuous dissociation (Zerach, Greene, Ginzburg, & Solomon, 2014) and enduring personality changes (Zerach & Solomon, 2013). Thus, although captivity may have ended years ago, many ex-POWs are still faced with the pathogenic effects of captivity on a daily basis, with their mental and physical state deteriorating more rapidly than their fellow noncaptured combatants (Solomon, Horesh, Ein-Dor, & Ohry, 2012). The widespread pathogenic consequences of captivity points to further questions regarding the risk for suicidality among exPOWs. However, although the association between PTSD and suicidal behavior among veterans has been thoroughly established (for review, see Pompili et al., 2013), only a limited number of empirical studies have systematically examined the association between captivity and SI (e.g., Hunt et al., 2008). More importantly, a recent study by our team found that among Israeli exPOWs, SI levels increased over a 17-year period, with posttraumatic stress symptoms (PTSS) affecting SI at each measurement (Zerach, Levi-Belz, & Solomon, 2014). Several possible theoretical understandings for the impact of captivity trauma on PTSD and SI may be offered. The first explanation concerns the amplification of the traumatic combatant experience through captivity. Captivity is known to extend the duration of the traumatic experience of war and further draw on the soldier’s already depleted coping resources. The severity of captivity may thus be compounded by isolation and loneliness, leaving a more profound and enduring traumatic imprint (Stein & Tuval-Mashiach, 2015). The second explanation is rooted in the aging process. In old age, one often has more time to reminisce and review one’s life, a process often accompanied by the recollection of early traumatic life events. This may be compounded by events associated with aging, such as bereavement, disease, or retirement, which may be particularly difficult for individuals who have suffered previous trauma, as they may trigger painful memories (e.g., Solomon et al., 1993). Third, one should also consider the unique interpersonal characteristics of captivity. The distinctive torments of captivity are part of a planned and concerted effort to “break” the individual through actions that are intentionally inflicted by captors on whom the captive may relate to on a daily basis and also on whom the person is dependent on in order to survive. This twisted relationship between captive and captor might leave a profound imprint with considerable implications for the future sense of an integrated self (Zerach, Levi-Belz, et al., 2014) and interpersonal relationships (Solomon, Dekel, & Zerach, 2009). The detrimental impact of war trauma often entails negative long-term consequences for trauma survivors’ wives (Figley, 1995). Recently, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5; American Psychiatric Association [APA], 2013) determined that indirectly exposed individuals may also meet the criteria for PTSD. Such secondary PTSD and PTSS have been studied extensively in veterans’ wives (e.g., Renshaw et al., 2011) and, to some extent, in ex-POWs’ wives (e.g., Zerach, Greene, & Solomon, 2015). Studies (e.g., Ahmadi, Azampoor-Afshar, Karami, & Mokhtari, 2011) have also

documented the existence of an association between wives’ PTSS and husbands’ PTSS. Despite a fair amount of research carried out in the past, the exploration of SI among veterans’ wives remains notably limited. Two studies have reported a 15% prevalence of SI among partners of veterans with PTSD (Manguno-Mire et al., 2007; O’Toole et al., 2015). An additional study has found that wives of veterans diagnosed with PTSD have reported higher levels of SI relative to a control group consisting of wives of veterans without PTSD (Klaric´ et al., 2012). It is plausible that ex-POWs’ wives are at an increased risk for PTSS and SI, first and foremost because they are often the main source of support for their husbands. As their husbands might suffer from PTSD, the wives may be exposed to various stressful behaviors from their husbands for a prolonged amount of time and, hence, are placed at risk (Hall & Simmons, 1973). A limited number of empirical studies (e.g., Meyler, Stimpson, & Peek, 2007) have attempted to explain the interactions between husbands’ and wives’ stress reactions. For example, a few studies have shown that exposure to significant others who suffer from major depression may increase the probability for depression in his or her spouse (e.g., Holahan et al., 2007). Concomitantly, it is possible that wives of traumatized veterans with SI can have similar emotional responses to situations that can lead to the development of depressive thinking (Joiner & Katz, 1999) and suicidality (Zhang & Zhou, 2011). Nevertheless, a recent study found no association between veterans and their partners for SI and suicide plans, and a weak relationship concerning suicide attempts (O’Toole et al., 2015). Furthermore, a recent study by our team found that among ex-POW couples, the more the husbands suffered from PTSS and SI, the weaker the increase of the wives’ SI was over time (Zerach, Levi-Belz, Michelson, & Solomon, 2016). The sparse and inconsistent literature regarding PTSS and SI among veterans and their partners calls for further investigation to consider possible variables moderating these links. Marital adjustment represents the degree to which couples are satisfied with their marital relationship in domains such as consensus, cohesion, affection, and expression. Thus, high levels of marital adjustment reflect a better quality of marital relations (Spanier, 1976). Decades of studies suggest that a safe, stable, nurturing relationship protects intimate adult partners against physical and mental health impediments (e.g., Karademas, 2014). However, the contribution of marital adjustment to suicidality is underresearched, with inconsistent results. Although most studies have shown that low marital quality and high marital distress (Robustelli, Trytko, Li, & Whisman, 2015) are related to high levels of SI, some studies among veterans have revealed no such association (e.g., Cigrang et al., 2015). Evidently, marital adjustment among spouses changes over the duration of the marriage. However, knowledge regarding the contribution of the changes and fluctuations in the marital adjustment to SI among at-risk groups is scarce. It is important to understand how long-term, established marital relations effect psychopathology—and SI levels, in particular. To our knowledge, no study has prospectively examined the contribution of marital adjustment to SI among partners of war veterans and ex-POWs. A decade of research has shown that war-induced psychopathology is implicated in veterans’ marital relation difficulties (e.g., Creech, Swift, Zlotnick, Taft, & Street, 2016). In this respect, a

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MARITAL ADJUSTMENT AND SUICIDAL IDEATION

recent meta-analysis found PTSD to be positively associated with intimate relationship discord as well as physical aggression (Taft, Watkins, Stafford, Street, & Monson, 2011). This is particularly relevant for captivity, as it is an interpersonal trauma in which the captor maintains a continuous, close, and coercive personal relationship with the victim. As such, this particular type of trauma can have a detrimental effect on the ex-POW’s future intimate relationships (Herman, 1992). The quality of marital relations not only may be directly associated with high levels of SI among veterans and their partners but also may have an indirect, moderating role in the link between their PTSS and SI. Indeed, positive marital adjustment can be part of any individual’s resource repertoire and serve as a major component of his or her social support to buffer SI (Santini, Koyanagi, Tyrovolas, & Haro, 2015). Among Iraq and Afghanistan war veterans, it was found that low social support moderated the link between PTSD and depression and SI (DeBeer, Kimbrel, Meyer, Gulliver, & Morissette, 2014). Alternatively, Jakupcak (2010) found that PTSD moderated the negative association between social support and SI. However, most of these studies were crosssectional, including the observation of only one partner of the dyad. In summary, recent multidimensional approaches have sought to discern the personal and interpersonal processes that may facilitate SI as well as suicidal behavior among at-risk groups (e.g., Nock et al., 2013), and also, in particular, to address the role of significant others within this interaction (Van Orden et al., 2010). In the present study, we prospectively examine both partners’ marital adjustment at the individual and dyadic levels, as well as its moderating role in the associations between personal and partners’ PTSS and SI over time. Moreover, although most of the studies in this field have used a cross-sectional design and individual observations, our study will examine the influence of marital adjustment both prospectively and bidirectionally. Thus, our results may open a window to understand the couple dyad as a factor that may be recognized as a resilience (or risk) factor for SI among ex-POWs. We hypothesize that, at the individual level (a) marital adjustment will be negatively related to husbands’ and wives’ PTSS and SI over time; (b) marital adjustment will contribute to husbands’ and wives’ SI over time, above and beyond husbands’ and wives’ own depressive symptoms, PTSS, and research group (i.e., exPOWs vs. controls); and, at the dyadic level, (c) husbands’ and wives’ marital adjustment will moderate the contribution of the husbands’ PTSS to their wives’ SI in T2, controlling for prior SI in T1; and (d) husbands’ and wives’ marital adjustment will moderate the contribution of the wives’ PTSS to the husbands’ SI in T2, controlling for prior SI in T1.

Method Participants The current study constitutes part of a larger longitudinal study assessing the psychosocial impact of war captivity (for more details, see Solomon et al., 2012). The sample consisted of 233 Israeli couples in which the husband was a veteran of the 1973 Yom Kippur War. According to Israel’s Ministry of Defense (IDF), 240 combat veterans from the Israeli infantry were captured during the 1973 Yom Kippur War and held captive either in Egypt

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or Syria for between 1 and 8 months. The sample was divided into the following two groups: (a) 142 ex-POWs and their spouses, and (b) 91 control couples in which the husband fought on the same fronts as the ex-POWs but was not held captive. The control veterans were sampled from IDF computerized data banks. They served in the same units as the ex-POWs and were matched to the ex-POWs for personal and military background characteristics. The groups were matched on the following personal and military variables: (a) military assignment—soldiers from the same unit and the same duty; and (b) scores on military performance prediction tests administered upon first being drafted—including personality features and measures of intelligence. Data were collected from husbands at three points in time (1991, 2003, 2008 –2010), and from wives at two points in time (2003–2004, 2010 –2011). The current study utilized a sample of opportunistic data collection from the husbands and wives at 2003–2004 (Time 1 [T1]) and 2008 –2011 (Time 2 [T2]). Ex-POWs and controls did not differ at T2 in age (M ⫽ 57.91, SD ⫽ 3.52, for ex-POWs; M ⫽ 57.89, SD ⫽ 3.57, for controls), length of marriage (M ⫽ 28.48, SD ⫽ 6.86, for ex-POWs; M ⫽ 26.44, SD ⫽ 6.41, for controls), divorce rate (5.5% of ex-POWs and 5% of controls had divorced), number of children (M ⫽ 3.27, SD ⫽ 1.12, for ex-POWS; M ⫽ 3.24, SD ⫽ 1.33, for controls), education, religiosity, or income. Of the participants in both groups, the mean years of schooling were 13.97 (SD ⫽ 3.93), 61.7% defined themselves as secular, 16.3% assessed their income as lower than average, 25.3% as average, 26.7% as somewhat higher than average, and 29.5% as much higher than average. The groups did not significantly differ in their levels of exposure to battlefield stressors in 1991 (ex-POWs, M ⫽ 1.83, SD ⫽ .62; controls, M ⫽ 1.69, SD ⫽ .68), F(1, 134) ⫽ 1.64, p ⫽ .20. We used a self-report questionnaire consisting of 23 items that formed four factors: encounters with death, life threatening situations, active fighting, and uncertainty. Cronbach’s alpha (␣) for the total scale was .90 (for more details, see Neria, Solomon, & Dekel, 1998). No significant differences were found between those who participated in the follow-up assessments with regard to rank, age, education, and the level of PTSD assessed in 1991. Ex-POWs’ wives. Of the 144 ex-POWs who took part in the 2003–2004 measurement, 111 were married or had a partner, and 82 of their wives participated in T1 (74% response rate). Of the 183 ex-POWs who participated in 2008 –2010, 147 were married or had a partner, and 116 of their wives participated in T2 (2010 – 2011; 79% response rate). Control wives. Of the 143 combat veterans who participated in the 2003–2004 measurement, 102 were married or had a partner, and 74 of their wives participated in T1 (73% response rate). Of the 118 combat veterans who participated in 2008 –2010, 103 were married or had a partner, and 56 of their spouses participated again in T2 (54% response rate). The demographic data for the wives sample obtained in T2 revealed no significant differences between the groups of wives in terms of country of birth, age, number of children, years of marriage/cohabitation, religiosity, and employment status. Wives’ ages ranged from 43 to 79 years old (M ⫽ 58.28, SD ⫽ 5.79). The duration of their marriage/cohabitation ranged from 2 to 60 years (M ⫽ 34.20, SD ⫽ 9.19), and they had an average of 3.23 children (SD ⫽ 3.00). Of all the wives, 47.7% had full-time jobs, 20.9% had part-time jobs, and 31.4% were unemployed. The groups

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differed in the level of education. Spouses of ex-POWs had fewer years of education (M ⫽ 14.16, SD ⫽ 3.20) compared with control spouses (M ⫽ 15.50, SD ⫽ 2.92).

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Measures PTSS. Husbands’ and wives’ PTSS were measured via the PTSD Inventory (PTSD–I; Solomon et al., 1993), a well-validated, 17-item, self-report questionnaire. The items on the PTSD–I correspond to the fourth edition of the DSM (DSM–IV–TR; APA, 2000) diagnosis for PTSD, which was the updated manual at the time of this study. It is important to note that the DSM–IV–TR (APA, 2000) and the DSM–5 (APA, 2013) share, with minor differences, the same 17 symptoms for PTSD. Respondents rated symptoms experienced in the previous month on a scale ranging from 1 (not at all) to 4 (almost always). Husbands’ current PTSS scores were obtained by asking husbands to rate their PTSS in relation to their own combat or captivity experiences. Wives’ PTSS scores were obtained by asking wives to rate their own PTSS specifically anchored to their husbands’ experiences of combat or captivity (e.g., “When I see or hear things that remind me of my partner’s captivity I have more severe sleep disturbances or oversensitivity to noise”). The number of positively endorsed symptoms was calculated by counting the items in which the respondents answered 3 (often) or 4 (almost always), as these responses best capture the DSM–IV–TR (APA, 2000) criteria of the “persistent” experience of these symptoms. Thus, the intensity of PTSS was operationalized as a continuous variable of PTSS based on the same symptoms as the dichotomized DSM diagnosis (i.e., PTSD). The inventory has proven psychometric properties in terms of high test–retest reliability (␣ ⫽ .93; Schwarzwald, Solomon, Weisenberg, & Mikulincer, 1987), concurrent validity, and convergent validity compared with structured clinical interviews conducted by trained psychiatrists and mental health professionals (Solomon, 1988). The reliability values for wives’ PTSS were Cronbach’s ␣ ⫽ .91 for T1 and ␣ ⫽ .90 for T2. Cronbach’s ␣ for husbands’ PTSS were ␣ ⫽ .95 for T1 and ␣ ⫽ .95 for T2. SI symptoms (SIS). SIS were assessed using two items from the Symptom Checklist-90 (SCL-90; Derogatis, 1977), known as one of the most widely used measures of multiple aspects of psychological distress in clinical practice and research. Participants were asked to indicate how frequently they experienced each symptom during the last 2 weeks on a 5-point distress scale (from 0 ⫽ not at all to 4 ⫽ very much). The two items used were (a) “thoughts about ending your life,” and (b) “thoughts about death and dying.” The use of these two items as a SI measure is common in studies on this topic (e.g., Srisurapanont et al., 2015). Because of the strong correlations between the two items at each measurement (r ⫽ .46 –.57), we calculated the mean score of the two items as the SI index, with a range of 0 to 5, which enabled us to also detect small changes in SI. Based on norms for psychiatric outpatients (Derogatis, 1977), scores above .73 were considered an indication of passing the clinical cutoff score. The SCL-90 has high concurrent validity and the specific subscales display high empirical agreement across various samples (Derogatis, Rickles, & Rock, 1976; Peveler & Fairburn, 1990); in addition, it has been widely used in the Israeli population. In this study, SI index reliability values for wives were Cronbach’s ␣ ⫽ .64 for T1 and

␣ ⫽ .49 for T2. Cronbach’s ␣ for husbands’ SI were ␣ ⫽ .68 for T1 and ␣ ⫽ .69 for T2. Dyadic Adjustment Scale (DAS). Marital adjustment was assessed using the DAS (Spanier, 1976), a 32-item scale divided into four subscales: Consensus, Cohesion, Satisfaction, and Affection Expression. Participants were asked to indicate the extent to which each item described their current marital interaction on a scale ranging from 1 (very low) to 6 (very high). The dyadic adjustment score is the sum rating of the 32 items, in which high scores reflect better adjustment. Heyman, Sayers, and Bellack (1994) reported that the scale has very good convergent validity and discriminant validity. The scale has been widely used among both clinical and normative populations all over the world (e.g., Horesh & Fennig, 2000). The DAS reliability values for wives were Cronbach’s ␣ ⫽ .95 for T1 and ␣ ⫽ .77 for T2, and for husbands’ were ␣ ⫽ .94 for T1 and ␣ ⫽ .83 for T2. Depressive symptoms. Depressive symptoms were assessed using the depression subscale of the SCL-90 (five items; Derogatis, 1977), with the omission of the two SI items. Participants were asked to indicate how frequently they experienced each symptom during the last 2 weeks on a 5-point Distress scale. For every participant, the average frequency of experiencing depressive symptoms was calculated for each assessment point. This specific SCL-90 subscale displays high empirical agreement across various samples (Derogatis et al., 1976; Peveler & Fairburn, 1990) and has been widely used in the Israeli population (e.g., Solomon, Shklar, & Mikulincer, 2005). The depressive symptoms variable was used as a statistical control variable. In this study, depressive symptom reliability values for wives were Cronbach’s ␣ ⫽ .91 for T1 and ␣ ⫽ .90 for T2. Cronbach’s ␣ for husbands’ depressive symptoms were ␣ ⫽ .87 for T1 and ␣ ⫽ .89 for T2.

Procedure Husbands and wives were located through contact information provided in previous waves of the longitudinal study (Greene, Lahav, Bronstein, & Solomon, 2014). Potential participants were sent a letter in which the present study was introduced and informed them that research assistants (licensed social workers) would contact them in the following weeks. After receiving an explanation of the aim of the present study, participants were offered the option of completing research questionnaires either in their homes or at a location of their choice. Informed consent was obtained from all participants. Approval for this study was given by the Tel Aviv University Ethics Committee.

Data Analyses To test our hypotheses, we started with Pearson analyses of intercorrelations between the study variables among research groups, conducted separately for husbands and wives. Next, we computed an actor–partner interdependence model (APIM; Kashy & Kenny, 2000), a data-analytic procedure designed to address violations of statistical independence that occur with dyadic data. In order to assess the appropriateness of the APIM, we used the Mplus sixth version software (Muthén & Muthén, 1998 –2010). All analyses were carried out with depressive symptoms as a covariate. The sample was defined by three criteria: (a) participants assigned to one of the study groups; (b) with a serial number that

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MARITAL ADJUSTMENT AND SUICIDAL IDEATION

allows the identification of spouses; and (c) at least one data report on wives’ main study variables at either T1 or T2. Accordingly, the present sample was comprised of 142 ex-POW couples and 91 control couples. Missing values analysis indicated that there were missing data in the variables. First, data were completed for participants that were missing data in the variables of wives’ PTSS at T1 (total missing values, n ⫽ 72 [30.6%]; ex-POWs wives, n ⫽ 50 [36.2%]; controls wives, n ⫽ 22 [22.7%]), wives’ PTSS at T2 (total missing values, n ⫽ 88 [37.4%]; ex-POWs’ wives, n ⫽ 38 [27.5%]; controls’ wives, n ⫽ 50 [51.5%]), husbands’ PTSS at T1 (total missing values, n ⫽ 50 [22.1%]; ex-POWs, n ⫽ 36 [26.1%]; controls, N ⫽ 16 [16.5%]), and husbands’ PTSS at T2 (total missing values, n ⫽ 45 [19.1%]; ex-POWs, n ⫽ 13 [9.4%]; controls, n ⫽ 32 [33%]). Second, data were completed for participants that were missing data in the variables of wives’ SI at T1 (total missing values, n ⫽ 76 [32.3%]; ex-POWs’ wives, n ⫽ 52 [37.7%]; controls’ wives, n ⫽ 24 [24.7%]), wives’ SI at T2 (total missing values, n ⫽ 76 [32.3%]; ex-POWs’ wives, n ⫽ 32 [23.2%]; controls’ wives, n ⫽ 33 [34%]), husbands’ SI at T1 (total missing values, n ⫽ 53 [22.6%]; ex-POWs, n ⫽ 35 [25.4%]; controls, n ⫽ 18 [18.6%]), and husbands’ SI at T2 (total missing values, n ⫽ 49 [20.9%]; ex-POWs, n ⫽ 16 [11.6%]; controls, n ⫽ 33 [34%]). Third, data were completed for participants that were missing data in the variables of wives’ dyadic adjustment at T1 (total missing values, n ⫽ 90 [38.3%]; ex-POWs’ wives, n ⫽ 60 [43.5%]; controls’ wives, n ⫽ 30 [30.9%]), wives’ dyadic adjustment at T2 (total missing values, n ⫽ 88 [37.4%]; ex-POWs’ wives, n ⫽ 38 [27.5%]; controls’ wives, n ⫽ 50 [51.5%]), husbands’ dyadic adjustment at T1 (total missing values, n ⫽ 67 [28.5%]; ex-POWs, n ⫽ 48 [34.8%]; controls, n ⫽ 19 [19.6%]), and husbands’ dyadic adjustment at T2 (total missing values, n ⫽ 70 [29.8%]; ex-POWs, n ⫽ 32 [23.2%]; controls, n ⫽ 38 [39.2%]). A series of attrition analyses were conducted. Those who participated in the study at T1 and T2 were compared with those who did not participate at each time point, in sociodemographic (age, education, income) and main study variables. A comparison of wives and husbands who participated in T1 with those who did not participate did not reveal any significant differences in the T2 sociodemographic or outcome variables. A comparison of wives

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who participated in T2 with those who did not participate did not reveal any significant differences in any of the T1 sociodemographic or outcome variables. A comparison of husbands who participated in T2 with those who did not participate did not reveal any significant differences in any of the T1 sociodemographics. However, husbands who participated in T2 reported higher levels of T1 PTSS (M ⫽ 7.52, SD ⫽ 5.70) compared with those who did not participate (M ⫽ 3.84, SD ⫽ 5.09), F(1, 141) ⫽ 11.08, p ⬍ .00. To assess whether the attrition was missing completely at random (MCAR), we conducted Little’s (1988) MCAR test. The analysis revealed that the data were not missing completely at random, ␹2(578) ⫽ 764.13, p ⬍ .001. Accordingly, statistical analysis for participants with complete information (common method of listwise deletion) could lead to a severe bias in the research results. In order to deal with the missing information, we used the method of multiple imputation (Rubin, 2009) using IBM SPSS statistics, Version 21.

Results Associations Between Research Variables Our first aim was to examine the interrelations between PTSS, SI, depressive symptoms, and marital adjustment among husbands and wives. Among ex-POWs and controls, husbands’ results revealed significant negative relations between marital adjustment and SI at each measurement point, as evident in Table 1 and 2 (T1: r ⫽ ⫺.32, p ⬍ .001 for ex-POWs, and r ⫽ ⫺.32, p ⬍ .001 for controls; T2: r ⫽ ⫺.29, p ⬍ .05 for ex-POWs, and r ⫽ ⫺.27, p ⬍ .01 for controls). Furthermore, significant positive relations between PTSS and SI were found at each measurement point (T1: r ⫽ .38, p ⬍ .01 for ex-POWs, and r ⫽ .62, p ⬍ .001 for controls; T2: r ⫽ .36, p ⬍ .01 for ex-POWs, and r ⫽ .56, p ⬍ .001 for controls) as well as between depression and SI at each measurement point (T1: r ⫽ .60, p ⬍ .001 for ex-POWs, and r ⫽ .63, p ⬍ .001 for controls; T2: r ⫽ .56, p ⬍ .001 for ex-POWs, and r ⫽ .57, p ⬍ .001 for controls). However, as demonstrated in Table 3 and Table 4, ex-POWs’ wives showed no significant relations between marital adjustment and SI in either of the measurement points. Among controls’ wives, however, marital adjustment was nega-

Table 1 Pearson Correlation Coefficients of PTSS, SI, Depressive Symptoms, and Marital Adjustment Among Ex-POWs at T1 and T2 Variables

1

2

3

4

5

6

7

8

1. PTSS (T1) 2. PTSS (T2) 3. SI (T1) 4. SI (T2) 5. Depression (T1) 6. Depression (T2) 7. Marital adj. (T1) 8. Marital adj. (T2) Mean Standard deviation

— .72ⴱⴱⴱ .38ⴱⴱ .32ⴱⴱⴱ .67ⴱⴱⴱ .54ⴱⴱⴱ ⫺.40ⴱⴱⴱ ⫺.25ⴱⴱⴱ 10.05 4.02

— .38ⴱⴱ .36ⴱⴱⴱ .59ⴱⴱⴱ .62ⴱⴱⴱ ⫺.27ⴱⴱⴱ ⫺.26ⴱⴱⴱ 9.89 4.58

— .51ⴱⴱⴱ .60ⴱⴱⴱ .49ⴱⴱⴱ ⫺.32ⴱⴱⴱ ⫺.15 .82 .71

— .30ⴱⴱⴱ .56ⴱⴱⴱ ⫺.29ⴱⴱⴱ ⫺.29ⴱⴱⴱ .86 .95

— .47ⴱⴱⴱ ⫺.32ⴱⴱⴱ ⫺.05 1.02 .71

— ⫺.39ⴱⴱ ⫺.51ⴱⴱⴱ 1.64 .94

— .68ⴱⴱⴱ 3.50 .51

— 2.35 .38

Note. N ⫽ 142. PTSS ⫽ posttraumatic stress symptoms; SI ⫽ suicidal ideation; ex-POWs ⫽ former prisoners of war; T1 ⫽ 2003–2004; T2 ⫽ 2008 –2011; adj. ⫽ adjustment. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

ZERACH, LEVI-BELZ, MICHELSON, AND SOLOMON

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Table 2 Pearson Correlation Coefficients of PTSS, SI, Depressive Symptoms, and Marital Adjustment Among Controls at T1 and T2 Variables

1

2

3

4

5

6

7

8

1. PTSS (T1) 2. PTSS (T2) 3. SI (T1) 4. SI (T2) 5. Depression (T1) 6. Depression (T2) 7. Marital adj. (T1) 8. Marital adj. (T2) Mean Standard deviation

— .59ⴱⴱⴱ .62ⴱⴱⴱ .26ⴱⴱ .69ⴱⴱⴱ .42ⴱⴱⴱ ⫺.20ⴱ ⫺.10 2.51 2.61

— .27ⴱⴱ .56ⴱⴱⴱ .42ⴱⴱⴱ .75ⴱⴱⴱ ⫺.18 ⫺.27ⴱⴱ 2.45 2.98

— .20ⴱ .63ⴱⴱⴱ .28ⴱⴱ ⫺.32ⴱⴱⴱ ⫺.15 .35 .38

— .10 .57ⴱⴱⴱ ⫺.14 ⫺.27ⴱⴱ .30 .45

— .33ⴱⴱ ⫺.23ⴱⴱ ⫺.03 .36 .38

— ⫺.13 ⫺.28ⴱⴱ .59 .62

— .79ⴱⴱⴱ 3.70 .54

— 2.51 .38

Note. N ⫽ 91. PTSS ⫽ posttraumatic stress symptoms; SI ⫽ suicidal ideation; T1 ⫽ 2003–2004; T2 ⫽ 2008 –2011; adj. ⫽ adjustment. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

tively related to SI at T2 (r ⫽ ⫺.29, p ⬍ .01). Moreover, significant positive relations between PTSS as well as depressive symptoms and SI at each measurement point were found (T1: r ⫽ .51, p ⬍ .001; T2: r ⫽ .50, p ⬍ .001).

The Direct and Moderated Effects of Marital Adjustment to SI in T2 An APIM was computed in order to examine whether husbands’ and wives’ marital adjustment directly contributed to SI in T2, and moderated the associations between husbands’ and wives’ PTSS and their SI in T2, while controlling for prior SI in T1. In this model, we examined the following questions: (a) Do husbands’ and wives’ marital adjustment directly contribute to SI in T2, while controlling for prior SI in T1?; (b) Do husbands’ and wives’ marital adjustment moderate the contribution of the husbands’ PTSS to the wives’ SI in T2, while controlling for prior SI in T1, above and beyond the contribution of the wives’ PTSS?; (c) Do husbands’ and wives’ perceptions of positive marital adjustment moderate the contribution of the wives’ PTSS to the husbands’ SI in T2, while controlling for prior SI and the husbands’ PTSS in

T1?; and (d) Does the research group moderate these processes? Standardized regression coefficients are presented in Table 5. The multigroup APIM model showed the best fit for the observed information, ␹2(8) ⫽ 7.46, p ⫽ .48, comparative fit index ⫽ 1.00, Tucker-Lewis index ⫽ 1.00, root mean square error of approximation ⫽ .00. Results showed that the more a wife reported a positive dyadic adjustment, the weaker the increase in her SI between T1 and T2, regardless of the study group. However, only in the control group was it found that the more a wife reported a positive marital adjustment, the weaker the increase in her husband’s SI between T1 and T2. Similarly, only in the control group was it found that the more a husband reported a higher level of marital adjustment, the weaker the increase in his SI between T1 and T2. Furthermore, for both the ex-POW and control groups, it was found that the husband’s marital adjustment moderated the contribution of his PTSS to his SI in T2, while controlling for prior SI in T1. As can be seen in Figure 1 (for the ex-POW group), among husbands with a low level of marital adjustment, as their PTSS level increased, the higher the increase in their SI was over time

Table 3 Pearson Correlation Coefficients of PTSS, SI, Depressive Symptoms, and Marital Adjustment Among Ex-POWs’ Wives at T1 and T2 Variables

1

2

3

4

5

6

7

8

1. PTSS (T1) 2. PTSS (T2) 3. SI (T1) 4. SI (T2) 5. Depression (T1) 6. Depression (T2) 7. Marital adj. (T1) 8. Marital adj. (T2) Mean Standard deviation

— .78ⴱⴱⴱ .22ⴱⴱ .16 .68ⴱⴱⴱ .54ⴱⴱⴱ ⫺.22ⴱ ⫺.43ⴱⴱⴱ 2.07 .50

— .34ⴱⴱⴱ .30ⴱⴱⴱ .67ⴱⴱⴱ .69ⴱⴱⴱ ⫺.13 ⫺.39ⴱⴱⴱ 6.01 3.57

— .58ⴱⴱⴱ .25ⴱⴱ .08 ⫺.14 ⫺.08 .47 .41

— .12 .23ⴱⴱ ⫺.16 ⫺.11 .48 .51

— .56ⴱⴱⴱ ⫺.14 ⫺.28ⴱⴱ .70 .43

— ⫺.21ⴱⴱ ⫺.44ⴱⴱⴱ .79 .45

— .54ⴱⴱⴱ 3.78 .50

— 3.61 .58

Note. N ⫽ 142. PTSS ⫽ posttraumatic stress symptoms; SI ⫽ suicidal ideation; ex-POWs ⫽ former prisoners of war; T1 ⫽ 2003–2004; T2 ⫽ 2008 –2011; adj. ⫽ adjustment. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

MARITAL ADJUSTMENT AND SUICIDAL IDEATION

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Table 4 Pearson Correlation Coefficients of PTSS, SI, Depressive Symptoms, and Marital Adjustment Among Controls’ Wives at T1 and T2 Variables

1

2

3

4

5

6

7

8

1. PTSS (T1) 2. PTSS (T2) 3. SI (T1) 4. SI (T2) 5. Depression (T1) 6. Depression (T2) 7. Marital adj. (T1) 8. Marital adj. (T2) Mean Standard deviation

— .68ⴱⴱⴱ .51ⴱⴱⴱ .31ⴱⴱⴱ .41ⴱⴱⴱ .50ⴱⴱⴱ ⫺.16 ⫺.24ⴱ 1.54 .27

— .42ⴱⴱⴱ .50ⴱⴱⴱ .45ⴱⴱⴱ .70ⴱⴱⴱ ⫺.25ⴱ ⫺.16 3.82 2.16

— .47ⴱⴱⴱ .63ⴱⴱⴱ .43ⴱⴱⴱ ⫺.08 ⫺.05 .38 .34

— .40ⴱⴱⴱ .56ⴱⴱⴱ ⫺.43ⴱⴱⴱ ⫺.29ⴱⴱ .51 .36

— .54ⴱⴱⴱ ⫺.39ⴱⴱⴱ ⫺.21ⴱ .56 .38

— ⫺.47ⴱⴱⴱ ⫺.35ⴱⴱ .64 .33

— .70ⴱⴱⴱ 3.79 .54

— 3.79 .54

Note. N ⫽ 91. PTSS ⫽ posttraumatic stress symptoms; SI ⫽ suicidal ideation; T1 ⫽ 2003–2004; T2 ⫽ 2008 –2011; adj. ⫽ adjustment. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

(b ⫽ .12, p ⬍ .00). Among husbands with a high level of marital adjustment, as their PTSS level increased, no significant increase in their SI was found over time (b ⫽ ⫺.02, p ⫽ .8). This process was similar both in the ex-POW and control groups. In addition, as can be seen in Figure 2, only in the control group did husbands’ marital adjustment moderate the contribution of their wives’ PTSS, thereby explaining husbands’ SI in T2, while controlling for prior SI in T1. Thus, it was found that among husbands with a low level of marital adjustment—the higher the wives’ PTSS level, the higher the increase in the husbands’ SI over the years (b ⫽ .89, p ⬍ .00). In contrast, among husbands with a high level of marital adjustment—the higher the wives’ PTSS level, the weaker the increase in the husbands’ SI over time (b ⫽ ⫺.67, p ⬍ .00).

Discussion In the present study, we prospectively examined the contribution of husbands’ and wives’ marital adjustment to their SI, among dyads of ex-POWs and noncaptive combat veterans and their respective partners. Furthermore, we examined the moderating role of marital adjustment in the longitudinal associations between husbands’ and wives’ PTSS and SI, at the dyadic level. As hy-

pothesized, our results revealed that lower marital adjustment was associated with higher SI at the individual level among ex-POWs, noncaptive combat veterans, and their wives. Notably, our other hypotheses were partially supported, as our results revealed that for both ex-POW and noncaptive combat veterans groups, husband’s marital adjustment moderated the contribution of his PTSS to his SI. Nevertheless, only for combat veterans did husbands’ marital adjustment moderate wives’ PTSS contribution to his SI in T2. To the best of our knowledge, this is the first prospective study examining the contribution of marital adjustment to SI among partners of war veterans and ex-POWs. Our results are consistent with most previous studies indicating that low marital quality and high marital distress (Robustelli et al., 2015) are related to high levels of SI, rather than those reporting no such association among veterans (e.g., Cigrang et al., 2015). It has been suggested that ex-POWS’ wives might have been compelled to take on the role of their husbands (i.e., child support, main provider) and thereby pushed aside or neglected their own needs (Zerach & Solomon, 2016). In this respect, Bernstein (1998) found that ex-POWs’ wives experienced feelings of abandonment, role ambiguity, and

Table 5 Standardized Regression Coefficients for Examination of Moderation Effects of Marital Adjustment on the Associations Between Husbands’ PTSS and Wives’ PTSS and Their SIs in T2, While Controlling for Prior SI in T1 Control couples

Ex-POW couples

Variables

Wives’ SI (T2)

Husbands’ SI (T2)

Wives’ SI (T2)

Husbands’ SI (T2)

Wives’ PTSS Husbands’ PTSS Wives’ marital adjustment Husbands’ marital adjustment Wives’ PTSS ⫻ Wives’ Marital Adjustment Husbands’ PTSS ⫻ Husbands’ Marital Adjustment Wives’ PTSS ⫻ Husbands’ Marital Adjustment Husbands’ PTSS ⫻ Wives’ Marital Adjustment

.05 ⫺.15ⴱ ⫺.32ⴱ .27 .11 .03 .02 .10

.07 .38ⴱⴱⴱ .60ⴱⴱⴱ ⫺.90ⴱⴱⴱ .15 ⫺.69ⴱⴱⴱ ⫺.42ⴱⴱⴱ .18

.15 ⫺.18ⴱⴱ ⫺.20ⴱⴱ .16 ⫺.17 ⫺.02 .05 .09

.05 .21ⴱⴱ .18 ⫺.01 ⫺.03 ⫺.26ⴱⴱ ⫺.04 .15

Note. PTSS ⫽ posttraumatic stress symptoms; SI ⫽ suicidal ideation; T1 ⫽ 2003–2004; T2 ⫽ 2008 –2011. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

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ZERACH, LEVI-BELZ, MICHELSON, AND SOLOMON

Figure 1. Husbands’ marital adjustment moderated husbands’ PTSS contribution to SI in T2, while controlling for prior SI in T1, among ex-POWs. PTSS ⫽ posttraumatic stress symptoms; SI ⫽ suicidal ideation; T1 ⫽ 2003–2004; T2 ⫽ 2008 –2011; ex-POWs ⫽ former prisoners of war.

suppressed anger. This pattern may be even further reinforced because of the Israeli traditional, family-oriented society that believes in family unity as a central value (Cohen, 2003). This may result in an overwhelming sense of responsibility for wives to maintain the marital relationship, which might, in turn, have inhibited their expression of SI. Nevertheless, when examining the moderating role of marital adjustment on the contribution of husbands’ and wives’ PTSS to SI over time, we found significant differences in group patterns. At the individual level, only in the controls did we find a large longitudinal moderating effect of veterans’ marital adjustment on their SI in T2, while controlling for prior SI in T1. Moreover, at the dyadic level, only among the controls did we find that wives’ marital adjustment moderated their husbands’ SI over time. Much to our surprise, no such moderating effects of marital adjustment on SI levels were found among the ex-POW dyads. Prior to the interpretation of the findings, it is important to note that the decision to include the measurements of 30 and 35 years after the war were opportunistic rather than deliberate. Therefore, the 5-year gap of dynamic factors that change frequently over time points to the need to

take the conclusion regarding the effect of marital adjustment on SI change with caution. Several possible explanations for this interesting pattern of results are provided. First, one needs to bear in mind that, unlike many other traumatic events, the extreme experiences of war captivity are recurrent and often persist for extended periods of time (Nazarian, Kimerling, & Frayne, 2012). More importantly, captivity trauma occurs in an interpersonal context under which a victim cannot escape and is deliberately traumatized and controlled by a captor (Herman, 1992). The captivity experience might also lead to an interpersonal psychological reaction that could impair the exPOWs’ marital adjustment and also their ability to ask for support from their significant others. Indeed, several studies have found that ex-POWS are less satisfied within their marital relationships (e.g., Zerach, Ben-David, Solomom, & Heruti, 2010). Thus, the impact of positive marital relationships in dealing with the devastating experience of SI may be hindered. Moreover, although the current study indicated that some ex-POWs may experience reasonable levels of marital adjustment, this failed to moderate SI over time, and did not function to decrease ex-POWs’ desires and

Figure 2. Husbands’ marital adjustment moderated wives’ PTSS contribution to SI’s in T2, while controlling for prior SI in T1, among controls. PTSS ⫽ posttraumatic stress symptoms; SI ⫽ suicidal ideation; T1 ⫽ 2003–2004; T2 ⫽ 2008 –2011.

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MARITAL ADJUSTMENT AND SUICIDAL IDEATION

wishes to end their lives. Interestingly, although marital adjustment did not moderate the ex-POWs’ SI over time, marital adjustment in T1 helped to reduce the levels of SI over time among ex-POWs’ wives, above and beyond their PTSS and depression levels. This difference emphasizes that although ex-POWs’ wives’ SI may be an interpersonal phenomenon in response to their husbands’ mental health condition (Zerach & Solomon, 2016), the ex-POWs’ SI would more accurately be considered an intrapersonal phenomenon. The difference in SI patterns among husbands and wives may also be understood as a gender difference in regard to the suicidal behavior continuum in the Western world in which women tend to have more suicidal thoughts as well as suicide attempts than men, whereas men die by suicide 4 times more than women (see Nock et al., 2013). Several authors have emphasized that one explanation for this “gender paradox” lies in the ability of women to communicate their suicidal crisis through words and actions. Their suicidal behavior can be a cry for help and reflect an interpersonal message (e.g., Nock, 2008). However, men tend to suppress their distress and suicidal thoughts from their relatives and friends, making it much more difficult to detect, and, as a result, their suicidal behavior is rendered more dangerous. Thus, the difference we found in the correlates of SI between ex-POWs and their wives suggests that the needs of husbands and wives are possibly different. Whereas wives need to solve their “ambiguous loss” (Boss, 1999) by becoming more differentiated and individual, ex-POWs need to find a way to become more interpersonally related (LeviBelz et al., 2014), and to use the help that is offered to them by their wives. Another plausible explanation for the differences between exPOWs and control veterans, concerning the ability to use positive marital adjustment to moderate SI, can be found in the interpersonal theory of suicide (Van Orden et al., 2010), which highlights the lack of belongingness and burdensomeness as two dimensions underlying SI. On the one hand, high levels of marital adjustment among control dyads reduced the possibility of a “thwarted belongingness” experience by enhancing the sense of perceived support and connectedness (Zerach & Solomon, 2016). On the other hand, ex-POWs may be prone to experiences of isolation and loneliness that hinder the fulfillment of needs, such as empathy and intersubjectivity (Stein & Tuval-Mashiach, 2015). Furthermore, as the detrimental psychological effects of war captivity are implicated in permanent and pervasive consequences that spread to PTSD and other mental and physical problems (e.g., Rintamaki et al., 2009), ex-POWs are also prone to “perceived burdensomeness,” which is known to be associated with the posttraumatic condition (Poindexter et al., 2015). Thus, ex-POWs might perceive themselves as a burden to their families (Cook, Riggs, Thompson, Coyne, & Sheikh, 2004). In contrast, because control veterans suffered from lower levels of PTSS and comorbidities, they might be less prone to seeing themselves as a burden and, as a result, their SI levels may be more likely to be reduced when their perceived marital adjustment is high. The fact that we did not find any moderation effect concerning marital adjustment among ex-POW dyads may also be attributed to the high proportion of delayed PTSD among Israeli ex-POWs (67%; Solomon et al., 2012). This means that at both measurement points, the levels of PTSD were high, which led to high levels of SI. It is conceivable that the delayed onset of PTSD inhibited the

9

ability of other factors, like marital adjustment, to moderate SI intensity among ex-POWs. However, the fact that there were low levels of PTSD symptoms and diagnoses in control veterans, this may have enabled marital adjustment to become a resilience factor that moderated SI. Of primary importance in the current study is the moderating effect on the contribution of PTSS to SI in T2, while controlling for prior SI in T1; this is the only result for which we found an effect of marital adjustment on SI in T2 among ex-POWs. This finding is consistent with the large body of research indicating that positive marital adjustment can help reduce the risk of negative psychopathological consequences following trauma (e.g., Santini et al., 2015). This specific moderation revealed that only the combination of high PTSS and low marital adjustment led to increases in SI levels over time. Thus, although this result reaffirms the centrality of high PTSS as a major risk factor for SI among veterans, it also emphasizes the negative facilitating effect of a conflictual marital relationship with low marital adjustment and satisfaction. In other words, when accompanied by high personal stress, embodied in PTSS, high interpersonal problems, such as low marital adjustment, can exacerbate stress and increase SI over time. This is consistent with other studies that have found this interaction of psychopathology (e.g., depression) and interpersonal problems as a contributor to both SI and severe suicide attempts in several clinical samples (Apter, Horesh, Gothelf, Graffi, & Lepkifker, 2001; Levi-Belz et al., 2014). This is also consistent with the interpersonal theory of Sullivan (1953), who stressed the importance of interpersonal relationships as the most crucial part of humanity, facilitating our willingness to live. Major difficulties in the area of interpersonal relationships, especially within spousal relationships, can be an indication for several psychopathologies, such as anxiety, depression, as well as suicidality. Several limitations concerning methodological issues of this study warrant mention. First, the use of self-report measures, although very common in trauma studies, entails a risk for reporting bias (e.g., social desirability), and this is especially true when addressing sensitive issues such as SI. Future studies should consider gathering data from multiple informants, such as the participants’ therapists, and use objective measures, such as an observation of actual functioning. Second, possible confounding variables (e.g., therapy for PTSD between measurements, other traumatic events, mental health more broadly) were not considered in the current study and should possibly be examined in future studies. Third, the lack of precombat assessment of personal and interpersonal functioning strongly limits our ability to infer causality. Thus, one cannot negate the contention that the current reports of SI of husbands and wives may be related to pretrauma conditions that may have contributed to the results, above and beyond the captivity experiences. Fourth, the interpretation of the results should be taken with caution because of high rate of missingness in the main study variables. Furthermore, significant differences between husbands who participated in T2 compared with those who did not participate in T1, particularly in relation to the reporting of levels of T1 PTSS, might have biased our results and presented an inaccurate and possibly more pathogenic condition. Fifth, our assessments did not cover the entire span of the 30 years since the war. Therefore, we were unable to monitor changes in the course of SI, as well as changes in marital adjustment, between 1973 and 2003. Therefore, it was not possible to under-

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stand the effect of marital relationships on SI during the earlier years of marriage. Sixth, as noted, because of possible changes in marital adjustment over the 5-year gap between T1 and T2, there is only a limited understanding of the impact of marital adjustment as relevant to changes in SI. Furthermore, the use of only two measurement points in this study restricts the ability of making solid assertions concerning stable patterns in SI as well as other factors. In addition, an absolute value of change does not address the level of severity, as an increase in 1 point in SI would be counted equally regardless of whether the change was from 0 to 1 or 1 to 2, although the actual difference is quite meaningful. Future studies should use more measurement points ranging across different periods of time, and investigate changes in SI as well as other related behaviors, such as suicide attempts and nonsuicidal self-injury. Last, although war captivity involves deliberate psychological and physical torment by captors over a long period of time, it is important to bear in mind that not all POWs have the same experience, and that the level of torment as well as the amount of time in captivity may vary.

Conclusions Despite the limitations, the current study yielded several important conclusions. First, the results emphasized the severity of the captivity experience by highlighting the possible limitations of positive marital adjustment in moderating the harsh consequences of the captivity-related residue, manifesting in SI. Second, the study results highlighted the significance of intrapersonal distress facilitating SI among ex-POWs (e.g., their own PTSS) in comparison with the interpersonal dimension moderating SI over time among ex-POWs’ wives and among controls’ wives (i.e., partners’ marital adjustment). Thus, it can be concluded that ex-POWs’ SI is more of a personal issue that should be treated separately from the couple-relationship context. However, with the ex-POWs’ wives, it can be concluded that they are more prone to depend on their significant others, as their SI levels were moderated by their husbands’ perception of marital adjustment. Following these conclusions, we can suggest a foundation for an integrative psychotherapeutic approach from which married exPOWs with SI may benefit. This approach may first and foremost include an individual intervention, wherein ex-POWs may process intrapersonal issues, such as their own trauma of captivity. However, gradually, the individual psychotherapy should be accompanied by family or couple interventions tapping interpersonal issues within the family and, in particular, attempt to assist ex-POWs to use the marital resources at their disposal in order to reduce distress and suicidality levels.

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ZERACH, LEVI-BELZ, MICHELSON, AND SOLOMON

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Received May 29, 2016 Revision received December 6, 2016 Accepted December 19, 2016 䡲

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