Original research| Volume 100, ISSUE 4, SUPPLEMENT , S76-S84, April 2019

Download started.


Resilience Among Caregivers of Injured Service Members: Finding the Strengths in Caregiving

Published:January 23, 2019DOI:



      To examine the relationships between caregiver resilience and a comprehensive set of sociodemographic and health-related quality of life (HRQOL) predictors among both caregivers and injured service members.


      Cross-sectional analysis of an observational cohort.


      Community dwelling.


      Caregivers (n=87) who provide instrumental or emotional support to injured service members (n=73)(N=160).


      Not applicable.

      Main Outcome Measure

      The Connor-Davidson Resilience Scale 25-item version.


      Higher caregiver resilience scores were related to lower depressive symptom severity, greater health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, stress management, and problem-solving orientation. A multivariable regression model showed that spiritual growth and aspects of problem-solving orientation were significantly related to resilience.


      Results highlight the relationships between resilience and spirituality, problem-solving orientation, and aspects of HRQOL among caregivers of injured service members. These findings have important implications for caregiver behavioral health programs designed to promote resilience and draw upon caregiver strengths when taking on a caregiver role. Approaches that include a more integrative medicine or strengths-based emphasis may be particularly beneficial when working with families of injured military.


      List of abbreviations:

      CD-RISC (Connor-Davidson Resilience Scale), CES-D (Center for Epidemiological Studies Depression Scale), CIM (Community Integration Measure), HPLP-II (Health-Promoting Lifestyle Profile), HRQOL (health-related quality of life), ICS (impulsivity/carelessness style), PCL-C (Posttraumatic Stress Disorder Checklist-Civilian), PTSD (posttraumatic stress disorder), SPSI-R (Social Problem-Solving Inventory-Revised), TBI (traumatic brain injury), TICS (Telephone Interview Cognitive Status)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Terhakopian A.
        • Sinaii N.
        • Engel C.C.
        • Schnurr P.P.
        • Hoge C.W.
        Estimating population prevalence of posttraumatic stress disorder: an example using the PTSD checklist.
        J Trauma Stress. 2008; 21: 290-300
        • Sammons M.
        • Batten S.
        Psychological services for returning veterans and their families: evolving conceptualizations of the sequelae of war-zone experiences.
        J Clin Psychol. 2008; 64: 921-927
        • Meyer K.S.
        • Marion D.W.
        • Coronel H.
        • Jaffee M.S.
        Combat-related traumatic brain injury and its implications to military healthcare.
        Psychiatr Clin North Am. 2010; 33: 783-796
        • Cifu D.X.
        • Cohen S.I.
        • Lew H.L.
        • Jaffee M.
        • Sigford B.
        The history and evolution of traumatic brain injury rehabilitation in military service members and veterans.
        Am J Phys Med Rehabil. 2010; 89: 688-694
        • French L.M.
        • Parkinson G.W.
        Assessing and treating veterans with traumatic brain injury.
        J Clin Psychol. 2008; 64: 1004-1013
        • Gondusky J.S.
        • Reiter M.P.
        Protecting military convoys in Iraq: an examination of battle injuries sustained by a mechanized battalion during Operation Iraqi Freedom II.
        Mil Med. 2005; 170: 546-549
        • Luethcke C.A.
        • Bryan C.J.
        • Morrow C.E.
        • Isler W.C.
        Comparison of concussive symptoms, cognitive performance, and psychological symptoms between acute blast-versus nonblast-induced mild traumatic brain injury.
        J Int Neuropsychol Soc. 2011; 17: 36-45
        • Hoge C.W.
        • McGurk D.
        • Thomas J.L.
        • Cox A.L.
        • Engel C.C.
        • Castro C.A.
        Mild traumatic brain injury in U.S. Soldiers returning from Iraq.
        N Engl J Med. 2008; 358: 453-463
        • Spencer R.J.
        • Drag L.L.
        • Walker S.J.
        • Bieliauskas L.A.
        Self-reported cognitive symptoms following mild traumatic brain injury are poorly associated with neuropsychological performance in OIF/OEF veterans.
        J Rehabil Res Dev. 2010; 47: 521-530
        • Griffin J.M.
        • Friedemann-Sanchez G.
        • Jensen A.C.
        • et al.
        The invisible side of war: families caring for US service members with traumatic brain injuries and polytrauma.
        J Head Trauma Rehabil. 2012; 27: 3-13
        • French L.M.
        Military traumatic brain injury: an examination of important differences.
        Ann N Y Acad Sci. 2010; 1208: 38-45
        • Kozminski M.
        Combat-related posttraumatic headache: diagnosis, mechanisms of injury, and challenges to treatment.
        J Am Osteopath Assoc. 2010; 110: 514-519
        • Okie S.
        Traumatic brain injury in the war zone.
        N Engl J Med. 2005; 352: 2043-2047
        • Stein M.B.
        • Kessler R.C.
        • Heeringa S.G.
        • et al.
        Prospective longitudinal evaluation of the effect of deployment-acquired traumatic brain injury on posttraumatic stress and related disorders: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
        Am J Psychiatry. 2015; 172: 1101-1111
        • Erbes C.
        • Westermeyer J.
        • Engdahl B.
        • Johnsen E.
        Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan.
        Mil Med. 2007; 172: 359-363
        • Dreer L.E.
        • Tang X.
        • Nakase-Richardson R.
        • et al.
        Suicide and traumatic brain injury: a review by clinical researchers from the National Institute for Disability and Independent Living Rehabilitation Research (NIDILRR) and Veterans Health Administration Traumatic Brain Injury Model Systems.
        Curr Opin Psychol. 2018; 22: 73-78
        • Elbogen E.B.
        • Wagner H.R.
        • Fuller S.R.
        • et al.
        Correlates of anger and hostility in Iraq and Afghanistan war veterans.
        Am J Psychiatry. 2010; 167: 1051-1058
        • Grieger T.A.
        • Cozza S.J.
        • Ursano R.J.
        • et al.
        Posttraumatic stress disorder and depression in battle-injured soldiers.
        Am J Psychiatry. 2006; 163: 1777-1783
        • Kuehn B.M.
        Military probes epidemic of suicide: mental health issues remain prevalent.
        JAMA. 2010; 304 (1429-30): 1427
        • Thomas J.L.
        • Wilk J.E.
        • Riviere L.A.
        • McGurk D.
        • Castro C.A.
        • Hoge C.W.
        Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq.
        Arch Gen Psychiatry. 2010; 67: 614-623
        • Bobo W.V.
        • Hoge C.W.
        • Messina M.A.
        • Pavlovcic F.
        • Levandowski D.
        • Grieger T.
        Characteristics of repeat users of an inpatient psychiatry service at a large military tertiary care hospital.
        Mil Med. 2004; 169: 648-653
        • Hoge C.W.
        • Castro C.A.
        • Messer S.C.
        • McGurk D.
        • Cotting D.I.
        • Koffman R.L.
        Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.
        N Engl J Med. 2004; 351: 13-22
        • Marx B.P.
        • Brailey K.
        • Proctor S.P.
        • Macdonald H.Z.
        • Graefe A.C.
        • Amoroso P.
        • et al.
        Association of time since deployment, combat intensity, and posttraumatic stress symptoms with neuropsychological outcomes following Iraq war deployment.
        Arch Gen Psychiatry. 2009; 66: 996-1004
        • Milliken C.S.
        • Auchterlonie J.L.
        • Hoge C.W.
        Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war.
        JAMA. 2007; 298: 2141-2148
        • Link P.E.
        • Palinkas L.A.
        Long-term trajectories and service needs for military families.
        Clin Child Fam Psychol Rev. 2013; 16: 376-393
        • Institute of Medicine
        Returning home from Iraq and Afghanistan: assessment of readjustment needs of veterans, service members, and their families.
        National Academies Press, Washington (DC)2013
        • Aiken L.
        • Bibeau P.
        • Cilentro B.
        • Boutin R.
        A personal reflection: a case study in family-centered care at the National Naval Medical Center in Bethesda, Maryland.
        Dimens Crit Care Nurs. 2010; 29: 13-19
        • Dausch B.M.
        • Saliman S.
        Use of family focused therapy in rehabilitation for veterans with traumatic brain injury.
        Rehabil Psychol. 2009; 54: 279-287
        • Moriarty H.
        • Winter L.
        • Robinson K.
        • et al.
        Exploration of individual and family factors related to community reintegration in veterans with traumatic brain injury.
        J Am Psychiatr Nurses Assoc. 2015; 21: 195-211
        • Doyle M.E.
        • Peterson K.A.
        Re-entry and reintegration: returning home after combat.
        Psychiatr Q. 2005; 76: 361-370
        • Christensen E.W.
        • Clinton Y.C.
        Demographics and burden on caregivers of seriously wounded, ill, and injured service members.
        J Dis Policy Studies. 2013; 23: 235-244
        • Tanielian T.
        • Ramchand R.
        • Fisher M.P.
        • Sims C.S.
        • Harris R.S.
        • Harrell M.C.
        Military caregivers: cornerstones of support for our nation's wounded, ill, and injured veterans.
        Rand Health Q. 2013; 3: 3
        • Wilder Schaaf K.P.
        • Kreutzer J.S.
        • Danish S.J.
        • Pickett T.C.
        • Rybarczyk B.D.
        • Nichols M.G.
        Evaluating the needs of military and veterans' families in a polytrauma setting.
        Rehab Psychol. 2013; 58: 106-110
        • Ramchand R.
        • Tanielian T.
        • Fisher M.
        • et al.
        Hidden heros: America’s military caregivers.
        RAND Corporation, Santa Monica2014
        • Taniellan T.
        • Bouskill K.E.
        • Friedman E.M.
        • Trail T.E.
        • Clague A.
        Improving support for America's hidden heroes: a research blueprint.
        Rand Health Q. 2018; 7: 9
        • Conforte A.M.
        • Bakalar J.L.
        • Shank L.M.
        • et al.
        Assessing military community support: relations among perceived military community support, child psychosocial adjustment, and parent psychosocial adjustment.
        Mil Med. 2017; 182: e1871-e1878
        • Ahmadi K.
        • Azampoor-Afshar S.
        • Karami G.
        • Mokhtari A.
        The association of veterans' PTSD with secondary trauma stress among veterans' spouses.
        J Aggress Maltreat Trauma. 2011; 20: 636-644
        • Verhaeghe S.
        • Defloor T.
        • Grypdonck M.
        Stress and coping among families of patients with traumatic brain injury: a review of the literature.
        J Clin Nurs. 2005; 14: 1004-1012
        • Phelan S.M.
        • Griffin J.M.
        • Hellerstedt W.L.
        • et al.
        Perceived stigma, strain, and mental health among caregivers of veterans with traumatic brain injury.
        Disabil Health J. 2011; 4: 177-184
        • Bass D.M.
        • Judge K.S.
        • Snow A.L.
        • et al.
        Negative caregiving effects among caregivers of veterans with dementia.
        Am J Geriatr Psychiatry. 2012; 20: 239-247
        • Brickell T.A.
        • French L.M.
        • Lippa S.M.
        • Lange R.T.
        Burden among caregivers of service members and veterans following traumatic brain injury.
        Brain Inj. 2018; 32: 1541-1548
        • Stevens L.F.
        • Lapis Y.
        • Tang X.
        • et al.
        Relationship stability after traumatic brain injury among veterans and service members: a VA TBI Model Systems study.
        J Head Trauma Rehabil. 2017; 32: 234-244
        • Chapin M.
        Family resilience and the fortunes of war.
        Soc Work Health Care. 2011; 50: 527-542
        • Saltzman W.R.
        • Pynoos R.S.
        • Lester P.
        • Layne C.M.
        • Beardslee W.R.
        Enhancing family resilience through family narrative co-construction.
        Clin Child Fam Psychol Rev. 2013; 16: 294-310
        • Melvin K.C.
        • Gross D.
        • Hayat M.J.
        • Jennings B.M.
        • Campbell J.C.
        Couple functioning and post-traumatic stress symptoms in US Army couples: the role of resilience.
        Res Nurs Health. 2012; 35: 164-177
        • Dreer L.
        • Girkin C.
        • Campbell L.
        • Wood A.
        • Gao L.
        • Owsley C.
        Glaucoma medication adherence among African Americans: program development.
        Optom Vis Sci. 2013; 90: 883-897
        • Dreer L.E.
        • Owsley C.
        • Campbell L.
        • Gao L.
        • Wood A.
        • Girkin C.A.
        Feasibility, patient acceptability, and preliminary efficacy of a culturally informed, health promotion program to improve glaucoma medication adherence among African Americans: “Glaucoma Management Optimism for African Americans Living with Glaucoma” (GOAL).
        Curr Eye Res. 2016; 41: 50-58
        • Connor K.M.
        • Davidson J.R.
        Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC).
        Depress Anxiety. 2003; 18: 76-82
        • Campbell-Sills L.
        • Stein M.B.
        Psychometric analysis and refinement of the Connor-Davidson Resilience Scale (CD-RISC): validation of a 10-item measure of resilience.
        J Trauma Stress. 2007; 20: 1019-1028
        • Marwitz J.H.
        • Sima A.P.
        • Kreutzer J.S.
        • et al.
        Longitudinal examination of resilience after traumatic brain injury: a Trumatic Brain Injury Model Systems study.
        Arch Phys Med Rehabil. 2018; 99: 264-271
        • Kreutzer J.S.
        • Marwitz J.H.
        • Sima A.P.
        • et al.
        Resilience following traumatic brain injury: a traumatic brain injury model systems study.
        Arch Phys Med Rehabil. 2016; 97: 708-713
        • Pietrzak R.H.
        • Cook J.M.
        Psychological resilience in older U.S. veterans: results from the national health and resilience in veterans study.
        Depress Anxiety. 2013; 30: 432-443
        • Monin J.K.
        • Levy B.R.
        • Pietrzak R.H.
        From serving in the military to serving loved ones: unique experiences of older veteran caregivers.
        Am J Geriatr Psychiatry. 2014; 22: 570-579
        • Bedard M.
        • Molloy D.W.
        • Squire L.
        • Dubois S.
        • Lever J.A.
        • O'Donnell M.
        The Zarit Burden Interview: a new short version and screening version.
        Gerontologist. 2001; 41: 652-657
        • Oberst M.
        • Thomas S.
        • Gass K.
        • Ward S.
        Caregiving demands and appraisal of stress among family caregivers.
        Cancer Nurs. 1989; 12: 209-215
        • Kreutzer J.S.
        • Marwitz J.H.
        • Sima A.P.
        • Godwin E.E.
        Efficacy of the brain injury family intervention: impact on family members.
        J Head Trauma Rehabili. 2015; 30: 249-260
        • Lin C.Y.
        • Wang J.D.
        • Pai M.C.
        • Ku L.E.
        Measuring burden in dementia caregivers: confirmatory factor analysis for short forms of the Zarit Burden Interview.
        Arch Gerontol Geriatr. 2017; 68: 8-13
        • Higginson I.J.
        • Gao W.
        • Jackson D.
        • Murray J.
        • Harding R.
        Short-form Zarit Caregiver Burden Interviews were valid in advanced conditions.
        J Clin Epidemiol. 2010; 63: 535-542
        • Walker S.
        • Sechrist K.
        • Pender N.
        The Health-Promoting Lifestyle Profile: development and psychometric characteristics.
        Nurs Res. 1987; 36: 76-81
        • Shinopulos N.M.
        • Jacobson J.
        Relationship between health promotion lifestyle profiles and patient outcomes of biofeedback therapy for urinary incontinence.
        Urol Nurs. 1999; 19: 249-253
        • Braden C.A.
        • Cuthbert J.P.
        • Brenner L.
        • et al.
        Health and wellness characteristics of persons with traumatic brain injury.
        Brain Inj. 2012; 26: 1315-1327
        • D'Zurilla T.
        • Nezu A.
        • Maydeu-Olivares A.
        Social Problem-Solving Inventory-Revised (SPSI-R): technical manual.
        Multi Health Systems, North Tonawanda, NY2002
        • D'Zurilla T.
        • Goldfried M.
        Problem solving and behavior modification.
        J Abnorm Psychol. 1971; 78: 107-126
        • Radloff L.
        The CES-D scale: a self-report depression scale for research in the general population.
        App Psychol Meas. 1977; 1: 385-401
        • Roberts R.
        • Vernon S.
        The Center for Epidemiologic Studies Depression Scale: its use in a community sample.
        App Psychol Meas. 1983; 1: 385-401
        • Weissman M.M.
        • Sholomskas D.
        • Pottenger M.
        • Prusoff B.A.
        • Locke B.Z.
        Assessing depressive symptoms in five psychiatric populations: a validation study.
        Am J Epidemiol. 1977; 106: 203-214
        • Husaini B.
        • Neff J.
        • Harrington S.
        • Hughes M.
        • Stone R.
        Depression in rural communities: validating the CES-D scale.
        J Comm Psychol. 1980; 36: 531-572
        • Blanchard E.
        • Jones-Alexander J.
        • Buckley T.
        • Forneris C.A.
        Psychometric properties of the PTSD Checklist (PCL).
        Behav Res Ther. 1996; 34: 669-673
        • Kang H.K.
        • Mahan C.M.
        • Lee K.Y.
        • Magee C.A.
        • Murphy F.M.
        Illnesses among United States veterans of the Gulf War: a population-based survey of 30,000 veterans.
        J Occup Environ Med. 2000; 42: 491-501
        • Ruggiero K.
        • Del Ben K.
        • Scotti J.
        • Rabalais A.
        Psychometric properties of the PTSD Checklist-Civilian Version.
        J Trauma Stress. 2003; 16: 495-502
        • Hoge C.W.
        • Terhakopian A.
        • Castro C.A.
        • Messer S.C.
        • Engel C.C.
        Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans.
        Am J Psychiatry. 2007; 164: 150-153
        • McColl M.A.
        • Davies D.
        • Carlson P.
        • Johnston J.
        • Minnes P.
        The community integration measure: development and preliminary validation.
        Arch Phys Med Rehabil. 2001; 82: 429-434
        • Minnes P.
        • Carlson P.
        • McColl M.
        • Nolte M.
        • Johnston J.
        • Buell K.
        Community integration: a useful construct, but what does it really mean?.
        Brain Inj. 2003; 17: 149-159
        • Brandt J.
        • Spencer M.
        • Folstein M.
        The Telephone Interview for Cognitive Status.
        Neuropsychiatry Neuropsychol Behav Neurol. 1988; 1: 111-117
        • Brandt J.
        • Folstein M.
        Telephone Interview for Cognitive Status (TICS). Professional manual.
        PAR, Lutz, FL2003
        • Lee H.B.
        • Richardson A.K.
        • Black B.S.
        • Shore A.D.
        • Kasper J.D.
        • Rabins P.V.
        Race and cognitive decline among community-dwelling elders with mild cognitive impairment: findings from the Memory and Medical Care Study.
        Aging Ment Health. 2012; 16: 372-377
        • Wilks S.E.
        • Spurlock W.R.
        • Brown S.C.
        • Teegen B.C.
        • Geiger J.R.
        Examining spiritual support among African American and Caucasian Alzheimer's caregivers: a risk and resilience study.
        Geriatr Nurs. 2018; 39: 663-668
        • Black K.
        • Lobo M.
        A conceptual view of family resilience factors.
        J Fam Nurs. 2008; 14: 33-55
        • Bormann J.
        • Warren K.A.
        • Regalbuto L.
        • et al.
        A spiritually based caregiver intervention with telephone delivery for family caregivers of veterans with dementia.
        Fam Community Health. 2009; 32: 345-353
        • Sharma V.
        • Marin D.B.
        • Koenig H.K.
        • et al.
        Religion, spirituality, and mental health of U.S. military veterans: results from the National Health and Resilience in Veterans Study.
        J Affect Disord. 2017; 217: 197-204
        • McCubbin H.
        • McCubbin M.
        Typologies of resilent families: emerging roles of social class and ethnicity.
        Fam Rel. 1988; 37: 247-254