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PTSD, play, and relationship satisfaction in OEF/OIF veterans

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PTSD, play, and relationship satisfaction in OEF/OIF veterans
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Betthauser, Lisa Marie ( author )
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English
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Operation Enduring Freedom, 2001- -- Veterans ( lcsh )
Iraq War, 2003-2011 -- Veterans ( lcsh )
Veterans -- Recreation ( lcsh )
Leisure -- Psychological aspects ( lcsh )
Post-traumatic stress disorder ( lcsh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Veterans returning from service in Afghanistan (OEF) and Iraq (OIF) may have experienced intense warfare, which can contribute to negative mental health issues, such as posttraumatic stress disorder (PTSD). PTSD has been repeatedly linked with poorer relationship functioning. Past research on PTSD and relationship functioning has focused primarily on negative outcomes with limited research on positive influences that function within the relationship for increasing relationship satisfaction. One positive strategy to promote relationship functioning is through shared leisure activities. However, PTSD may interfere with Veterans ability to either participate or enjoy such activities. To my knowledge, no studies have examined these topics in OEF/OIF Veterans. To address this gap, this study explored Veteran appraisal of shared leisure with their intimate partners with increased specificity regarding frequency and affect during various types of such activities. I hypothesized that less frequent shared leisure, greater negative affect during leisure, and/or less positive affect during leisure would mediate associations between PTSD and relationship satisfaction in this sample. A sample of 68 OEF/OIF Veterans provided self-report data on these constructs. A unique contribution of this study was the development and initial testing of psychometric properties of the Positive Leisure Activities with You (PLAY). In general, the results of this study demonstrate that the pilot measure tested in this sample is a reliable and valid measure of shared leisure activity. The evidence as a whole supports the basic validity of the PLAY subscales. When proceeding to hypothesis testing, there were unexpected findings regarding the interrelationships between PTSD, PLAY and relationship satisfaction. One significant correlation was found between PTSD avoidance symptoms and relationship satisfaction; no other PTSD and relationship satisfaction associations were significant. Also, PTSD was not associated with frequency of PLAY. There were interesting patterns regarding significant associations between PTSD and negative affect during PLAY. Finally, results confirmed prior literature regarding the associations between shared leisure and relationship satisfaction. Overall, these results provides some support for promoting shared leisure activities, with consideration of the affective experience and the potential impact of PTSD symptoms, to increase relationship satisfaction.
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Includes bibliographical references.
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by Lisa Marie Betthauser.

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Full Text
PTSD, PLAY, AND RELATIONSHIP SATISFACTION IN OEF/OIF VETERANS
by
LISA MARIE BETTHAUSER
B.A., University of Colorado, Boulder, 2003
M.B.A., University of Colorado at Denver, Denver, 2006
M.A., University of Colorado at Denver, Denver, 2012
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Clinical Health Psychology Program
2016


This thesis for the Doctor of Philosophy degree by
Lisa Marie Betthauser
has been approved for the
Clinical Health Psychology Program
by
Krista Ranby, Chair
Elizabeth Allen, Advisor
Lisa A. Brenner
Jim Grigsby


Betthauser, Lisa, Marie (Ph.D., Clinical Health Psychology)
PTSD, PLAY and Relationship Satisfaction in OEF/OIF Veterans
Thesis directed by Associate Professor Elizabeth Allen
ABSTRACT
Veterans returning from service in Afghanistan (OEF) and Iraq (OIF) may have experienced
intense warfare, which can contribute to negative mental health issues, such as posttraumatic
stress disorder (PTSD). PTSD has been repeatedly linked with poorer relationship functioning.
Past research on PTSD and relationship functioning has focused primarily on negative outcomes
with limited research on positive influences that function within the relationship for increasing
relationship satisfaction. One positive strategy to promote relationship functioning is through
shared leisure activities. However, PTSD may interfere with Veterans ability to either
participate or enjoy such activities. To my knowledge, no studies have examined these topics in
OEF/OIF Veterans. To address this gap, this study explored Veterans appraisal of shared leisure
with their intimate partners with increased specificity regarding frequency and affect during
various types of such activities. I hypothesized that less frequent shared leisure, greater negative
affect during leisure, and/or less positive affect during leisure would mediate associations
between PTSD and relationship satisfaction in this sample. A sample of 68 OEF/OIF Veterans
provided self-report data on these constructs. A unique contribution of this study was the
development and initial testing of psychometric properties of the Positive Leisure Activities with
You (PLAY). In general, the results of this study demonstrate that the pilot measure tested in this
sample is a reliable and valid measure of shared leisure activity. The evidence as a whole
m


supports the basic validity of the PLAY subscales. When proceeding to hypothesis testing, there
were unexpected findings regarding the interrelationships between PTSD, PLAY and
relationship satisfaction. One significant correlation was found between PTSD avoidance
symptoms and relationship satisfaction; no other PTSD and relationship satisfaction associations
were significant. Also, PTSD was not associated with frequency of PLAY. There were
interesting patterns regarding significant associations between PTSD and negative affect during
PLAY. Finally, results confirmed prior literature regarding the associations between shared
leisure and relationship satisfaction. Overall, these results provides some support for promoting
shared leisure activities, with consideration of the affective experience and the potential impact
of PTSD symptoms, to increase relationship satisfaction.
The form and content of this abstract are approved. I recommend its publication.
Approved: Elizabeth Allen


DEDICATION
I dedicate this work to my curious, resilient, and playful son, Trystan Roarke Betthauser Hayes. I
look forward to many years of play with you. I also dedicate this work to my family and mentors
that supported and encouraged me through all the trials and tribulations on this fantastic journey.
v


ACKNOWLEDGMENTS
I would like to thank Dr. Lisa Brenner, Dr. Elizabeth Allen, Dr. Jim Grigsby, and Dr. Krista
Ranby for their invaluable input and guidance. I would like to thank the research team at the
Rocky Mountain Mental Illness, Research, Education and Clinical Center at the Denver Veterans
Affairs Medical Center for the assistance and support of this project. I extend my greatest
appreciation for all the brave men and women who have dedicated their lives and loyalty to
ensuring our freedom in this beautiful country.
This publication is based on work supported by the Department of Veterans Affairs, but does not
necessarily represent the views of the Department of Veterans Affairs or the United States
Government.
vi


TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION..........................................................1
II. REVIEW 01 THE LITERATURE..............................................3
PTSD in OEF/OIF Veterans..............................................3
PTSD..................................................................3
PTSD, Veterans & Interpersonal Relationships..........................4
Positive Relationship Factors.........................................6
PTSD Symptoms & Shared Activities.....................................9
Current Study........................................................10
Specific Aims........................................................12
Aim 1.............................................................12
Aim 2.............................................................12
Hypotheses..................................................12
Aim 3.............................................................13
Hypothesis..................................................13
III. METHOD...............................................................14
Procedure............................................................14
Consent & HIPAA Authorization Procedure..............................14
Participants.........................................................15
Demographics......................................................15
Relationship Status.........................................18
vii


Measures
19
Posttraumatic Stress Disorder Checklist Civilian (PCL-C).................19
Kansas Marital Satisfaction Scale (KMSS)...................................20
Positive Leisure Activities with You (PLAY)................................20
Measures for Validation of the PLAY Scales.....................................21
Marital Activities Profile (MAP)...........................................22
Arons items of excitement in relationships................................23
Additional Measures of Relationship Satisfaction...............................23
Couples Satisfaction Index (CSI-4).........................................23
Satisfaction with Marital Life Scale (SWMLS)...............................24
Data Analysis..................................................................24
Power Analysis.................................................................24
Data Assumptions & Corrections.................................................24
IV. RESULTS........................................................................25
Posttraumatic Stress Disorder Checklist (PCL-C)....................................25
Relationship Satisfaction..........................................................26
Marital Activities Profile (MAP) Scale & Aron Item.................................27
Aim 1..............................................................................28
28
viii
PLAY Psychometrics


PLAY Frequency Scales........................................28
PLAY Affect Scales...........................................30
Construct Validity of PLAY...................................30
Validation of PLAY Affect..........................................33
Construct Validity of PLAY Continued: Extension to Additional
Measures.....................................................39
Aim 2....................................................................43
PTSD & Relationship Satisfaction...................................46
PTSD & PLAY........................................................47
PLAY & Relationship Satisfaction...................................50
PLAY Affect & Relationship Satisfaction............................51
Aim 3....................................................................52
V. DISCUSSION............................................................53
PLAY Psychometric Properties.............................................53
Interrelationships between PTSD, PLAY & Relationship Satisfaction........55
VI. LIMITATIONS...........................................................60
VII. CONCLUSIONS & IMPLICATIONS............................................62
REFERENCES......................................................................63
IX


APPENDIX
72
A: PLAY Measure.................................................................73
B: PLAY Scales..................................................................81
C: Predicted Correlation Matrix.................................................84
D: Mediation Figure.............................................................86
x


LIST OF ABBREVIATIONS
CSI-4
DSM-IV-TR
ECHCS
KMSS
MAP
OEF
OIF
PCL-C
PLAY
PTSD
SWMLS
VA
Couples Satisfaction Index 4
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition Text Revision
Eastern Colorado Healthcare System
Kansas Marital Satisfaction Scale
Marital Activities Profile
Operation Enduring Freedom
Operation Iraqi Freedom
Posttraumatic Stress Disorder Checklist Civilian
Positive Leisure Activities with You
Posttraumatic Stress Disorder
Satisfaction with Marital Life Scale
Veterans Affairs
xi


CHAPTER I
INTRODUCTION
United States (U.S.) military troops deployed since 2001 provided the most sustained
ground combat military operations since the Vietnam conflict (Friedman, 2005). Significant
numbers of troops deployed to Iraq and Afghanistan have been exposed to intense guerilla
warfare, chronic threats of improvised explosive devices (IEDs), and roadside bombs over
multiple and extended deployments (Hoge et al., 2004). Exposure to prolonged, violent combat
situations has been shown to be correlated with negative physical and mental health outcomes
(Prigerson et al., 2002, Tanelian & Jaycox, 2008). Post-traumatic stress disorder (PTSD) is one
of the most common and prevalent mental health disorders associated with stressful combat
experiences (Hoge et al., 2004; Hoge et al., 2006; Tanelian & Jaycox, 2008). Not only does
PTSD and subclinical PTSD have a negative impact on a Veterans ability to function post-
deployment, but it also detrimentally affects his or her significant others, as well as his or her
families. In fact, Veteran endorsement of PTSD symptoms is reliably associated with decreased
relationship satisfaction (Lambert, Engh, Hasbun, & Holzer, 2012; Nelson Goff, Crow, Reisbig,
& Hamilton, 2007; Newby, McCarroll, Ursano, Fan, Shigemura, & Tucker-Harris, 2005; Riggs,
Byrne, Weathers, & Litz, 1998; Taft, Stafford, Watkins, Street & Monson, 2011). Although
research has suggested that increasing social support and reducing negative social interactions
may mitigate the development of chronic PTSD (Sautter, Armelie, Glynn, & Wielt, 2011),
relatively fewer studies have examined strategies to mitigate decreases in relationship
satisfaction when symptoms of PTSD are present. One strategy that might mitigate decreases in
relationship satisfaction when symptoms of PTSD are present is increasing the amount of time
couples spend together engaging in pleasurable activities. For couples in general, spending time
1


together and engaging in pleasurable activities are important strategies for enduring relationship
quality and satisfaction (Dindia & Baxter, 1987; Holman & Epperson, 1989; Orthner & Mancini,
1991). One way PTSD may be related to decreased relationship satisfaction is by reduced shared
leisure activities, for example, due to PTSD related numbing or avoidance symptoms which may
lead to avoiding even leisure activities with the partner. If this is the case, increasing shared
leisure activities for couples with PTSD could help to improve relationship functioning.
However, to my knowledge, no literature has explored whether couple engagement in shared
leisure activities mediates the associations between PTSD and relationship satisfaction.
Therefore, the goals of this study were to thoroughly explore the associations between PTSD,
relationship satisfaction, and shared leisure activities with the partner in OEF/OIF Veterans, and
to test whether such shared activities mediate the association between PTSD and relationship
satisfaction for the Veteran.
2


CHAPTER II
REVIEW OF THE LITERATURE
PTSD in OEF/OIF Veterans
Over 2.3 million individuals have been deployed in support of the Global War on Terror,
including deployments to Iraq and Afghanistan (Environmental Health Strategic Healthcare
Group, 2011). For Veterans serving in Operation Enduring Freedom (OEF; Afghanistan) and
Operation Iraqi Freedom (OIF; Iraq) prolonged exposure to combat-related stress has been linked
to an increase in psychological disorders such as PTSD (Tanielian & Jaycox, 2008). Estimates of
PTSD prevalence in the OEF/OIF Veteran population spans a wide range, with recent findings
noting a range of 11-22% (Finley, Baker, Pugh, & Peterson, 2010), and previous estimates
finding 10-44% of OEF and/or OIF Soldiers surveyed report clinically significant PTSD
symptoms (Erbes et al., 2007; Hoge et al., 2004; Lapierre, Schwegler, & Labauve, 2007; Seal et
al., 2007). Seal and colleagues (2007) looked at OEF/OIF Veterans seeking services at the
Department of Veterans Affairs and found a 13% prevalence of PTSD based on the ICD-9-CM
diagnosis. Furthermore, Seal et al. (2007) found a significant increased risk of PTSD and mental
health diagnoses in the youngest OEF/OIF age group (ages 18-24) as compared to Veterans 40
years and older. As more of the Soldiers serving in the Iraq and Afghanistan wars return home
and transition out of active duty to civilian life, the psychological impact of combat exposure is
an increasing public concern.
PTSD
PTSD is an anxiety disorder that can develop from exposure to a traumatic event which
involves threat, or occurrence, of severe injury or death to oneself or to others. Traumatic events
that may cause PTSD include accidents, natural disasters, violent assaults, and military combat.
3


Diagnostic criteria of PTSD include three symptom clusters: 1) re-experiencing the event, 2)
persistent avoidance of things associated with the event/numbing of emotions, and 3)
hyperarousal (DSM-IV-TR, American Psychological Association, 2000). Individuals may re-
experience the traumatic event in various ways, such as through recurrent, intrusive memories,
dreams, or flashbacks. These recollections are frequently associated with distress and heightened
arousal (APA, 2000). Persistent and deliberate avoidance of thoughts, feelings, activities,
situations or people comprise the avoidance cluster of PTSD symptoms. Also included in this
symptom cluster is emotional numbing. Emotional numbing often is expressed as diminished
interest or participation in previously enjoyed activities; feelings of detachment from
interpersonal relationships; and a reduced ability to feel emotions, specifically emotions
associated with physical and emotional intimacy. Hyperarousal symptoms are frequently
described as persistent symptoms of anxiety or arousal, such as hypervigilance, exaggerated
startle response, and increased irritability or outbursts of anger.
Many negative outcomes also are associated with PTSD symptoms, including decreased
physical functioning and emotional well-being (Erbes et al, 2007; Zatzick et al. 1997), decreased
quality of life and mortality (Pietrzak et al., 2010; Tanielian & Jaycox, 2008), and greater
problems in interpersonal functioning (Pietrzak et al., 2010).
PTSD, Veterans & Interpersonal Relationships
Research has found that Veterans with PTSD report greater frequency and severity of
relationship problems and poor family adjustment. Such issues may lead to higher divorce rates
for combat Veterans with PTSD as compared to combat Veterans without PTSD (Cook, Riggs,
Thompson, Coyne, & Sheikh, 2004; Jordan et al., 1992). Two recent meta-analyses (Lambert,
Engh, Hasbun, & Holzer, 2012; Taft, Stafford, Watkins, Street, & Monson, 2011) have
4


supported prior findings regarding the association between PTSD and family relationships,
specifically noting significant associations between military-related PTSD and intimate
relationship issues. Negative impacts of PTSD on Veterans relationships include poorer
communication, greater relationship instability, and problems with relationship adjustment,
positive bonding, commitment, and communication (Allen, Rhoades, Stanley, & Markman,
2010; Meis, Erbes, Polusny, & Comptom, 2010; Monson, Taft, & Fredman, 2009; Nelson Goff,
Crow, Reisbig, & Hamilton, 2007; Ray & Vanstone, 2009; Riggs et al., 1998).
Riggs and colleagues (1998) proposed reasons on why PTSD may affect intimate
relationships. For example, these authors suggest that hyperarousal symptoms of PTSD, such as
hypervigilance, increased irritability, and impaired concentration skills may serve to increase
conflict and distress within the relationship (Riggs et al., 1998). Moreover, emotional exchange
is thought to be inhibited by PTSD-specific symptoms of emotional numbing, such as restricted
affect, detachment, loss of interest in activities, and an inability to communicate intimacy and
love (Feeney, Zoellner, Fitzgibbons, & Foa, 2000; Riggs et al, 1998). In fact, Riggs and
colleagues (1998) found that the avoidance symptom cluster including emotional numbing and
effortful avoidance symptoms were significantly correlated to lower relationship satisfaction.
Emotional numbing symptoms also may lead to decreases in self-disclosure with loved ones,
which has been found in male Veterans with chronic PTSD (Carroll, Rueger, Foy, & Donahoe,
1985). Self-disclosure has been found to partially mediate the relationship between avoidance
symptoms and marital intimacy (Solomon, Dekel, & Zerach, 2008). These consequences are
especially concerning as increased difficulties in relationships in turn often contribute to the
persistence of PTSD symptoms (Barrett & Mizes, 1988).
5


Positive Relationship Factors
Past research on PTSD and relationship functioning has focused primarily on negative
outcomes such as increases in conflict, distress, domestic violence, and divorce, with limited
research on potential distinct positive influences that function within the relationship for
increasing and/or maintaining relationship satisfaction. This mirrors the general literature in
clinical psychology on couple functioning, which has sought to closely examine more negative
aspects of relationship functioning such as distress and conflict. However, there is a call in this
general literature to increase exploration of more positive psychological factors in relationship
functioning (Fincham & Beach, 2010; Freeman, Moore, & Freeman, 2009), such as fun,
friendship, positive bonding, shared activities, and leisure time (Aron, Norman, Aron, McKenna,
& Heyman, 2000; Johnson, Zabriskie, & Hill, 2006). Prior literature has shown that spending
time together and engaging in pleasurable activities as a couple is an important strategy for
enduring quality and satisfaction within a relationship (Dindia & Baxter, 1987; Holman &
Epperson, 1989; Orthner & Mancini, 1991). Aron et al. (2000) suggests that maintenance of
relationship satisfaction occurs through self-expansion in the relationship via continuous
engagement in shared activities that are novel and exciting. This suggestion originates from Aron
and Arons (1986) self-expansion model which proposes that the individual is motivated to
expand the self through acquired knowledge, experience, identities and other resources (Aron &
Aron, 1986). As the early honeymoon phase of the relationship passes and self-expansion slows,
the exhilaration and novelty of the relationship declines. Couples who continue to seek joint
activities that are new and challenging may experience positive effects and subsequently attribute
these effects to the relationship quality (Aron et al., 2000). The process of sharing in new and
exciting activities has been associated with feelings of pleasure, arousal, and excitement (Aron,
6


Aron, & Norman, 2001). As long as self-expansion and associated positive feelings occur, it is
hypothesized that relationship satisfaction and quality increase (Strong & Aron, 2006). Aron and
colleagues (2000) have explored this theory and found that couples who engaged in shared
activities that are novel and challenging show increases in relationship satisfaction.
The importance of both new and expansive activities for couples, as well as sharing of
more common activities, are delineated in Johnson and colleagues (2006) Core and Balance
Model of shared leisure patterns in couples. The Core and Balance Model subsumes two patterns
of leisure: Core (common, everyday activities), and Balance (novel, less frequent activities). The
process of engaging in such activities assists the couple in meeting their needs of stability and
change (Zabriskie & McCormick, 2001). Core activities consist of common, every day,
accessible, low-cost, and often home-based activities that the couples may do frequently.
Watching movies/television, cooking dinner together, gardening, or playing board games are
examples of Core activities. On the other hand, Balance activities consist of engaging in
interactions that are less common and less frequent and typically provide a relatively novel
experience. Balance activities are usually not considered home-based, and may require more
resources. Outdoor recreation, attending amusement parks or music concerts, and vacations are
examples of these types of activities. Furthermore, Balance activities are unpredictable and
necessitate adaptation to new experiences and challenges (Zabriskie & McCormick, 2001).
While the Core and Balance Model is rooted in family systems theory and has been applied to
family leisure patterns (Zabriskie & McCormick, 2001), more recent research has begun to
investigate the use of this model in examining couples relationship satisfaction (Johnson et al.,
2006).
7


As noted, the positive affect experienced in shared leisure is important to healthy
relationship functioning. As described above in the self-expansion model, Aron and colleagues
(2000) have demonstrated that positive emotions, such as pleasure and excitement during novel
and exciting activities, are a primary factor in concomitant increases in relationship satisfaction
and feelings of closeness. Fredricksons broaden-and-build theory of positive emotion (1998;
2001) furthers the importance of positive emotion in relationship functioning. This theory posits
that when individuals feel positive emotions they experience a greater sense of oneness with
other people. Fredrickson (1998) highlights positive emotions including joy, interest,
contentment, and love, all of which may serve as factors that generate and expand romantic
relationships. In the broaden-and-build theory, joy is conceptualized as a relative high-arousal
positive emotion, interest is presented as interchangeable with excitement, and is associated with
challenge, and contentment as a low-arousal positive emotion that arises in contexts perceived as
safe and with a high degree of certainty. Love is defined by Fredrickson (1998) as an
amalgamation of positive emotions with the emphasis that love experiences must be felt towards
specific individuals. Love, combined with joy, interest, and contentment, experienced within the
intimate relationship contributes to the broadening and building of the individuals physical,
psychological, intellectual and social resources. This is consistent with Aron & Arons (1986)
self-expansion model with an emphasis on increasing positive emotions to spark growth in
personal resources and interpersonal relationships.
Taking all this into account, if partners are able to engage each other in positive emotion
during leisure, this may serve to improve relationship satisfaction and functioning. This may be
an especially important area of intervention for Veterans who are experiencing PTSD and their
partners, as PTSD may itself inhibit this area of connection for couples.
8


PTSD Symptoms & Shared Activities
As discussed above, PTSD symptoms have shown negative impacts on relationship
quality and satisfaction (Galovski & Lyons, 2004; Monson et al., 2009). Related to the issue of
shared leisure, Riggs et al. (1998) suggests that emotional numbing and avoidance may decrease
participation in leisure activities and positive affect (as noted above, an important element in the
bonding process of shared leisure). PTSD symptoms such as hypervigilance, the need for control,
high startle response, and constant alertness may cause the Veteran to become irritable, angry,
and on guard, also while interfering with chances to enjoy a new experience and share positive
emotions with their partner. PTSD symptoms may also lead the individual to avoid crowds, loud
noises, or other stimuli associated with a shared activity that mimics or triggers memories of the
traumatic event may inhibit the individual from engaging in new and/or exciting activities with
his or her partner (e.g. amusement parks, movies, concerts). Thus, considering the symptoms of
PTSD and how these symptoms may manifest in the relationship, there may be a number of ways
that the frequency and/or enjoyment of shared leisure with a romantic partner may be affected.
That is, PTSD may decrease shared leisure, through hypervigilance or emotional numbing,
limiting emotional expression and shared intimacy, which in turn may decrease relationship
satisfaction. In fact, these interactions between PTSD symptoms and shared leisure can be
cyclical, as the loss of shared activities subsequently may affect the individuals ability to be
emotionally expressive and share intimacy with his or her partner, decreasing relationship
satisfaction.
In support of this overall conceptualization of the links between PTSD, shared leisure,
and marital adjustment, Allen et al. (2010) found that a measure of positive bonding, which
included questions about fun and friendship, partially mediated the relationship between PTSD
9


symptoms and marital satisfaction for Active Duty soldiers and their spouses. However, this
measure only included three broad and nonspecific items regarding fun and friendship (e.g. We
have a lot of fun together, We regularly make time for fun activities together as a couple, and
We have conversations where we just talk as good friends); only one of those referring to
activities specifically. Thus, there is a lack of data exploring the links between PTSD, shared
leisure, and marital adjustment in a more detailed manner.
Current Study
To address this gap in knowledge, I will explore the Veterans appraisal of shared leisure
with their intimate partners with increased specificity regarding various types of shared leisure
and the affect experienced during shared leisure activities. That is, I will explore types of leisure
that encompass both Core and Balance activities, and Arons delineation of activities that are
novel, and I will also explore the associated emotional experience during the activity type (i.e.,
reflecting Fredricksons broaden-and-build theory of emotion). I will then examine how the
frequency and emotional aspects of shared leisure may mediate the relationship between PTSD
symptoms and marital quality. If the hypothesized relationships are found, it may support the
inclusion of maximizing couple play in current interventions such as cognitive-behavioral
conjoint therapy for PTSD (Monson & Fredman, 2012).
A unique contribution of this study was the creation of a pilot measure to assess
frequency of, and affect regarding, various shared activities. Goals for this study include (1) an
examination of the psychometric properties of the pilot measure, and (2) to use psychometrically
adequate scales from this measure to assess the relationships among the variables of interest and
test the hypotheses. The pilot measure is called the Positive Leisure Activities with You (PLAY)
measure. This measure was informed by reviewing existing research by Aron and colleagues
10


(2000), by the Core and Balance model of leisure activities (Johnson et al., 2006; Zabriskie &
McCormick, 2001), and by the broaden-and-build theory of emotion (Fredrickson, 1998; 2001).
First, the measure was designed to assess frequency of participation in various types of PLAY,
that is, shared activities that are normal/routine (Routine), new/different (Novel), and
exciting/thrilling (Exciting). This was done by asking a single item frequency and scale
frequency (i.e., responding to a set of adjectives) designed to respectively assess Routine, Novel,
and Exciting activities, using a Likert rating scale. In addition to the various types of PLAY
assessed in this manner, overall frequency of PLAY can be assessed by combining all these
frequency items into a combined scale of Overall PLAY frequency.
Second, the measure assesses the emotions associated with the various types of PLAY.
Aron and colleagues (2000), and Fredrickson (1998; 2001) assert that the emotional aspect of
shared activities is integral to the maintenance and/or expansion of relationship satisfaction.
Many reactions to various types of PLAY are possible, including theoretically plausible reactions
of distress, anxiety, or numbness as would be posited in the case of PTSD. For example, going to
a concert may be very stressful, rather than fun, for a person with the hypervigilance symptoms
of PTSD. Therefore, the measure provides a list of emotion words informed by the broaden-and-
build theory of positive emotion (Fredrickson, 1998; 2001), the Positive and Negative Affect
Schedule (PANAS; Watson, Clark & Tellegan, 1988), as well as PTSD literature. Respondents
are asked to rate the frequency of each emotion associated with each type of activity. That is, a
list of emotion words is presented three times, per category of activity (1) Routine; 2) Novel; and
3) Exciting), and respondents indicate how often they experience that emotion during that type of
activity. Please see Appendix A for the PLAY measure.
11


Specific Aims
Under each Aim, a priori hypotheses have been considered and are presented below.
Aim 1
To establish basic psychometric adequacy of the PLAY measure. The first aim of the
current study focused on psychometric evaluation of the PLAY measure. Scales have been
rationally-derived for this proposal and are described in the Data Analysis section below. The
scales are included in Appendix B. Tests of Cronbachs alpha will be run iteratively, deleting
items as needed, until a final set of items with good internal consistency have been established
per scale. Each scale will then be evaluated with a series of criterion validity tests. This
sequencing of rational development of a scale combined with statistical tests of psychometric
adequacy is a content, or rational-empirical, approach to scale construction. This approach was
adopted for a number of reasons, including limited power to conduct procedures such as factor
analysis and the fact that these scales were derived a priori based on theory. Please see Results
for further elaboration of the tests of reliability and validity for this measure. After the PLAY
scales are finalized per Aim 1, they will be used for Aims 2 and 3.
Aim 2
To better understand interrelationships among the variables. Interrelationships among
core variables of interest (PTSD, PLAY, relationship satisfaction), as well as the various
components of these variables (i.e., PTSD symptom clusters, types of PLAY, emotional aspects
of PLAY) will be analyzed using a correlation matrix. Please see Appendix C for the proposed
correlation matrix.
Hypotheses
12


Overall, I predicted that PTSD symptom severity would be negatively correlated with
PLAY frequency and relationship satisfaction. Furthermore, the various components of these
variables (PTSD symptom clusters, types of PLAY frequency, emotional aspects of PLAY,
relationship satisfaction) are hypothesized to be significantly correlated in the directions noted
(e.g., high PTSD would be associated with low PLAY).
Aim 3
To test whether PLAY is a mediator between PTSD and marital satisfaction. I
hypothesized that the relationship between PTSD symptoms and relationship satisfaction for the
Veteran will be significantly mediated by the Veterans engagement in shared leisure activities
with the partner. Please see Appendix D for the proposed mediational model.
Hypothesis
Greater PTSD symptom severity will predict decreased frequency of PLAY, which in
turn will predict decreased relationship satisfaction. This general hypothesis will be evaluated
with various scales/clusters of the constructs.
13


CHAPTER III
METHOD
Procedure
Participants were recruited at the Denver Veterans Affairs Medical Center (DVAMC,
part of the ECHCS) in the following ways: 1) approved flyers were posted around the DVAMC
and given to staff, 2) Veterans who completed informed consent for a research repository
database were referred to the study; and 3) I attended primary health and mental health care staff
meetings to inform DVAMC staff of the study. Inclusion criteria specified that participants were
OEF/OIF Veterans who had received services at the DVAMC, were between the ages of 18 and
50, and reported having a current, intimate relationship that was at least one year in duration. A
waiver of HIPAA authorization was obtained at COMIRB initial approval to allow members of
the research team to record personal information needed for screening via telephone. Eligible
participants were screened in-person or via telephone and were invited to the DVAMC for an
approximate two-hour appointment to complete consent and study procedures.
Consent & HIPAA Authorization Procedure
Approved study team members conducted all procedures regarding consent to participate
in the study and authorization to collect protected health information (PHI). All research team
members were trained in COMIRB procedures. All approved study team members reported to
me. All study regulatory procedures were conducted by me under the supervision of Dr. Brenner
at the VA and Dr. Allen at the University of Colorado at Denver (UCD). Informed consent was
obtained from participants by reading the consent and by explaining the nature of the study and
potential risks and benefits in a calm environment at the DVAMC. Participants were given ample
time to ask questions and, if they agreed to participate, they were given a copy of his or her
14


signed and dated consent. The participants were then asked to complete the following five
questions to ensure comprehension: 1) What are you being asked to do? 2) Finish this sentence -
The purpose of this study is to find out... 3) True or False: After beginning this study, you can
decide not to continue at any time, without penalty. 4) What should you do if you have questions
about this study? 5) Who should you call if you feel you have been harmed in the study?
(Janofsky, McCarthy, & Folstein, 1992). All participants answered these items adequately.
Separate from constructs used in the current study, measures regarding suicide risk were
included (see Appendix E for the complete set of measures included in the study). Participants
were informed that Dr. Brenner or her designee might review their responses to questions
regarding burdensomeness and belongingness and self-directed violence, and if necessary, would
discuss these responses with them and their treating clinician to ensure their safety. No
participant exceeded the safety monitoring criteria.
Participants
Participants were recruited from the population of OEF and/or OIF Veterans seeking or
eligible to receive healthcare within the Veterans Affairs (VA) Eastern Colorado Health Care
System (ECHCS). Approval for the study was obtained from the Colorado Multiple Institutional
Review Board (COMIRB) prior to any procedures. Sixty-eight Veterans completed all study
procedures.
Demographics
Please see Table 1. The majority of the sample were male (86%). Most participants were
Caucasian (78%), 10% identified as African American, 9% as Hispanic ethnicity, and the rest
self-identified their ethnicity as Other. The average age of Veterans was 34 years (SD = 7
years; range 23-50).
15


The average years of education completed was 14.71 (SD = 2.14). Income was reported
as household income, which could have included personal salary, benefits, and/or partner salary
or benefits. Approximately 17% reported income of less than $24,999, 18% reported an income
of $25,000 $34,999, 19% reported an income of $35,000 $49,999, 20% reported an income of
$50,000 $74,999, and 22% reported an income equal to or greater than $75,000. Half of the
sample reported unemployment, 29% employed full-time, 10% employed part-time, and 10%
retired. Forty-four percent of the Veterans also reported being a student.
Most Veterans reported Active Duty service in the Army (57.4%), followed by Marine
Corp (19.1%), Navy (13.2%) and Air Force (7.4%). Veterans also reported National Guard and
Reserves military service. Please see Table 1 for complete details. Veterans served an average of
5.33 years (SD = 11.3 months) in the military prior to separation from the service.
16


Table 1
Demographic Characteristics
Characteristics
(n=68)
Male 58 (86%)
Age 34 (7.0)
Median & Range 33 (23, 50)
Race/Ethnicity
Caucasian 53 (78%)
African American 7 (10%)
Hispanic 6 (9%)
Other 2 (3%)
Years of Education 14.71 (2.14)
Employment
Full Time 20 (29.4%)
Part Time 7 (10.3%)
Retired 7 (10.3%)
Unemployed 34 (50.0%)
Student 30 (44.1%)
Household Income
< $24,999 14 (17.3%)
$25,000 $34,999 12 (17.7%)
$35,000 $49,999 27 (57.4%)
> $75,000 15 (22.1%)
Branch of Service*
Army 39 (57.4%)
Army National Guard 6 (8.8%)
Army Reserves 8(11.8%)
Air Force 5 (7.4%)
Air Force Reserves 2 (3%)
Navy 9(13.2%)
Navy Reserves 3 (4.4%)
Marines 13 (19.1%)
Marine Reserves 2 (30%)
Coast Guard 1 (1.5%)
Length of Military Service 5.33 (11.3 months)
Numbers represent N (%) or Mean (SD)
*Numbers do not equal 100% as Veterans may have served in multiple Military Services.
17


Relationship Status
Sixty percent of the participants were married. Of the married participants, 58% were in
their first marriage, 37% were in their second marriage, and 5% were in their third marriage. The
current average dating duration prior to marriage was 1.7 years (SD = 1.42 years), and the
current average marital relationship was 7.55 years (SD = 6.48 years). Over three-quarters of the
married participants (78%) reported having children.
Forty percent of the sample were in a dating relationship, and 37% of those reporting a
dating relationship had a prior divorce. The current average dating relationship was 2.75 years
(SD = 1.42 years). Forty-eight percent of those in a dating relationship reported having children.
Complete relationship status characteristics are presented in Table 2.
Table 2
Relationship Status Characteristics
Relationship Status
Married 41 (60%)
First Marriage 24 (58%)
Second Marriage 15 (37%)
Third Marriage 2 (5%)
Length of Relationship Prior 1.7 years (1.42)
to Marriage
Length of Marriage 7.55 years (6.48)
Have Children 32 (78%)
No. of Children 2.38 (1.18)
Dating 27 (40%)
Prior Divorce 10 (37%)
Length of Relationship 2.75 years (1.42)
Have Children 13 (48%)
No. of Children .85 (1.1)
Numbers represent N (%) or Mean (SD)
18


Measures
Core measures for testing the hypotheses specified in the aims are presented below in
Table 3 and described below
Table 3
Core Measures for Hypothesis Testing
Measure Domain Application of
PTSD Checklist-Civilian (PCL-C) PTSD symptoms IV
Kansas Marital Satisfaction Scale (KMSS) Relationship Satisfaction DV
Positive Leisure Activities With You Leisure Mediator
Posttraumatic Stress Disorder ChecklistCivilian (PCL-C)
The PCL-C (Weathers, Litz, Herman, Huska, & Keane, 1993) is a 17-item self-report
measure that assesses respondents endorsement of the level of distress that co-occurred with
each PTSD symptom in the last 30 days. Items on the PCL-C parallel diagnostic criteria for
PTSD in the DSM-IV. A five-point scale is used to rate each item (1 = not at all, 5 =
extremely).The PCL-C can be used as a continuous measure of symptom severity by summing
all 17 items, or items can be summed and interpreted based on the DSM-IV PTSD criteria and
core symptoms (avoidance, hyperarousal, emotional numbing). The National Center for PTSD
has suggested cut-off scores on the PCL for assisting in the diagnosis of PTSD, depending on the
target setting (U.S. Department of Veterans Affairs, 2014). In the general population settings, the
cut-off score suggested is 30-35, but it is 36-44 in specialized medical clinics/VA primary care,
and 45-50 in VA and/or civilian mental health clinics. The PCL-C has demonstrated excellent
reliability (a = .97, test-retest r = .96) in prior samples of Vietnam Veterans, and had good
19


sensitivity (.82) and specificity (.83) for a SCID diagnosis of PTSD (Weathers, et al., 1993). For
this study, the total PTSD score was summed, and each symptom sub-cluster was summed.
Kansas Marital Satisfaction Scale (KMSS)
The KMSS (Schumm et al, 1986) is a brief measure of relationship satisfaction. It has 3-
items that assess for satisfaction with the marriage, marital relationship, and the character of
ones spouse. For this study, this has been modified to fit a sample that includes non-marital
relationships by modifying the following terms: (question 1) term marriage to relationship,
(question 2) term husband/wife to partner, (question 3) husband/wife to significant other
and spouse to partner. Items are rated on a 7-point Likert scale (1 = extremely dissatisfied, 7
= extremely satisfied). The KMSS has high internal consistency, concurrent validity with other
measures of marital quality, and criterion validity with marital instability measurements (for a
review see McLeland, Sutton, & Schumm, 2008). The KMSS score was averaged for use in
analyses.
Positive Leisure Activities with You (PLAY)
As discussed earlier, the PLAY measure is designed to more specifically assess
frequency of types of shared leisure activities with the partner, and the degree of actual pleasure
experienced during various types of activities. The first three items on the PLAY assessed for
frequency of activities that were Routine, Novel, and Exciting. These three items were each rated
on a scale of 1 to 5 (1 = once a month, 5 = five or more times a month). These three single-item
frequency questions were each used respectively as a frequency of that type of PLAY, and also
averaged for an Overall Frequency score of PLAY.
Next, participants were presented with 46 adjectives designed to assess the concepts of
routine, novel, and exciting leisure as well as additional words not predicted to
20


conceptually fall onto the three scales (i.e., Routine, Novel, Exciting). Participants were asked to
rate how often they engaged activities that fit each adjective with their partner on a 5-point Likert
scale (1 = Not at all; 5 = Very often).
Finally, individuals were presented with emotion words that were a priori believed to
represent positive, negative, and neutral affect. There were 50 positive (N = 22), negative (N =
25) and neutral (N = 3) emotion words. Respondents were asked to rate the frequency of the
specific emotion when they engaged in (a) Novel, (b) Routine, and (c) Exciting leisure activities
with their partner. The frequency of these affect words during the respective activities was rated
on a 5-point Likert scale (1 = Not at all; 5 = Very often). Whereas there exist measures that
assess frequency and type of leisure activities, to my knowledge, no measure assesses affect
experienced during shared leisure. This is an important construct to measure, as Fredrickson
(1998) posits the broadening and building of intimate relationships through the experience of
shared positive emotion. This measure is included in Appendix A and E. Psychometric properties
of this measure are presented in the Results.
Measures for Validation of the PLAY Scales
The Marital Activities Profile and Arons items were used in data collection for the
purpose of validation of the PLAY measure. These measures are presented in Table 4 and
described further below.
21


Table 4
Measures to validate the PLAY scales
Measure Domain Application of
Assessed Variable
Marital Activities Profile (MAP) Shared Leisure Validation
Arons items of excitement and Excitement in Validation
degree of exciting activities in current relationship relationships
Marital Activity Profile (MAP)
The MAP is a 15-item questionnaire measuring couples leisure involvement and leisure
satisfaction. Zabriskie and McCormick (2001) modified the MAP from the Family Leisure
Activity Profile (FLAP) based on the Core and Balance Model of Family Leisure Functioning,
replacing the phrase with your family to with your spouse and adapting some activity
questions to better reflect couple (as opposed to family) interactions and communication.
Participants are asked if they participate in 15 types of activities. If the participant positively
endorses the activity, additional questions ask about the frequency (at least: daily, weekly
monthly, annually), duration (< 1 hour to >1 day for Core activities; < 1 hour to 3 or more weeks
for Balance activities), and satisfaction with level of participation with spouse for each activity.
Although there are no existing psychometric properties for the MAP, the original FLAP has
demonstrated good construct validity, content validity, and test-retest reliability for core and
balance activities (Zabriskie, 2001). For the purpose of this study, additional modifications
replaced the phrase spouse to significant other to be more inclusive of relationship status. In
order to calculate a translatable score of frequency of Core and Balance activities, the overall
Core and Balance scales were computed using the frequency item only. That is, participants
responses to frequency of each activity (e.g., daily, weekly, monthly, annually) were used to
22


determine the average score and scale reliabilities. I did not include the duration part of the
coding as I needed a scale that represented simple frequency of the activity.
Arons Items of Excitement in Relationships
A three-item questionnaire developed by Aron, Norman, Aron, McKenna, & Heyman
(2000) assessed the degree of excitement: 1) within the relationship, and 2) of activities shared in
the relationship. Specifically, the questions are: How bored are you with your current
relationship?, How exciting is your current relationship and, How exciting are the things you
do together with your partner?. The questions are answered on a 5-point scale ranging from 1
(not at all) to 5 (extremely). This exciting activities question has demonstrated a strong positive
association with experienced relationship quality (r = .5l,p< .001) (Aron et al., 2000). For
PLAY validation and subsequent correlation and regression analyses, only the third item How
exciting are the things you do with your partner? was used. This item was used as it best
represented another measure of participation in frequency of exciting activities with the partner.
Additional Measures of Relationship Satisfaction
To help explore the impact of PTSD and PLAY on relationship satisfaction, additional
measures of relationship satisfaction were included.
Couples Satisfaction Index (CSI-4)
The CSI is a measure of relationship satisfaction with 32, 16 or 4 item forms. The CSI
was constructed using item response theory using the Marital Adjustment Test, the Dyadic
Adjustment Scale, and 75 additional satisfaction items. The four-item version was used in this
study. The first item is rated on a 7-point Likert scale (1 = extremely unhappy, 7 = extremely
happy) and the following three items rated on a 6-point Likert scale (1 = not at all true, 7 =
completely true). The CSI scales have demonstrated adequate convergent validity and excellent
23


construct validity with previous relationship satisfaction scales (Funk & Rogge, 2007). The four
items were summed to generate a total score and used in analyses.
Satisfaction with Marital Life Scale (SWMLS)
This five-item measure is included at the end of the Marital Activities Profile, and was
modified by Ward and colleagues (2009) from the Satisfaction with Life Scale (Diener,
Emmons, Larson, & Griffin, 1985) as a measure of global marital satisfaction. The items are
rated on a Likert scale from 1 (strongly disagree) to 7 (strongly agree). Ward and colleagues
(2009) found excellent internal consistency of this measure (a = .94), as well as face, criterion
and construct validity. The mean score for each participant was used for analyses.
Data Analysis
All analyses, except for power analyses, were conducted using the Statistical Package for
the Social Sciences (SPSS) version 22. Each Aim and associated statistical analyses are
presented below.
Power Analysis
Power analyses were conducted using G*Power to determine the sample size needed in
order to conduct the proposed analyses. To detect medium effects in the most complex analysis
to be used (i.e., a regression with two predictors) a sample size of 68 was needed and was met as
the recruitment goal for this study.
Data Assumptions & Corrections
The proposed study includes several analyses, which increases the likelihood for Type I
error. Rather than apply Bonferroni corrections, which would require very large effect sizes to
achieve significance, I proposed to take a pattern approach to evaluating the randomness of the
findings.
24


CHAPTER IV
RESULTS
Prior to use in analyses, all measures integral to hypothesis testing were assessed for
internal consistency and descriptive properties. Reliabilities and scale details for this sample are
presented below.
Posttraumatic Stress Disorder Checklist Civilian (PCL-C)
Please see Table 5 for the PCL-C scale statistics. The PCL-C total symptom severity and
Re-experiencing symptom cluster score demonstrated excellent reliability (a > .90). PCL-C
Avoidance and Hyperarousal symptom cluster scores demonstrated good reliability (a = .88,
respectively). The convention for the PCL is to present summed values. The average total PCL
score in this sample was 43.2. According to cut off suggestions by the National Center for PTSD
delineated above, the average level in this sample exceeds some of the cutoffs used for
diagnostic purposes for PTSD. On a cluster level, the average sum of 12.41 on the re-
experiencing scale and the average sum of 16.58 on the avoidance score would both represent
an average item rating of 2.4 on the items on that scale, which lands between a little bit and
moderately bothered by those symptoms. The average sum of 14.82 on the hyperarousal
cluster score would represent an average rating of 3.0 on those items, indicating moderately
bothered by those symptoms.
25


Table 5
PCL-C scale statistics
No. Items M SD a
PTSD Total 17 43.2 16.6 .94
PTSD Re-experiencing 5 12.41 5.59 .90
PTSD Avoidance 7 16.58 7.08 .88
PTSD Hyperarousal 5 14.82 5.84 .88
Note: Means represent averages of the summed items on that scale.
Relationship Satisfaction
Please see Table 6 for relationship satisfaction scale statistics. All three measures of
relationship satisfaction demonstrated excellent reliability (a > .90). Higher mean scores indicate
greater relationship satisfaction. Both the KMSS and SWMLS are rated on a 7-point Likert scale.
On average, the participants are reporting a qualitative description of being somewhat satisfied
relationship satisfaction based on the KMSS. Crane, Middleton, and Bean (2000) have
recommended a cut-off score of 5.67, such that individuals whom endorse lower scores are more
dissatisfied in their relationship and individuals whom endorse higher scores are more satisfied
in their relationship. The average score for participants on the SWMLS indicate relationship
satisfaction at slightly above neither agree nor disagree. Compared to a community sample that
found participants had an average score of 5.7 (Ward et al., 2009), the Veteran participants in the
current study endorsed relatively less relationship satisfaction on the SWMLS with an average
score of 4.53. On the CSI-4, the lowest score possible is a 4 and the highest score possible is 25.
The average total score for this sample was 17.3. Luebcke and colleagues (2014) recommend a
distress cutoff score of 13 on the CSI-4, with higher scores indicating greater relationship
satisfaction. Thus, in two of the relationship satisfaction measures (KMSS and SWMLS), the
26


current sample is, on average, either in the distressed range or relatively more distressed than a
community sample, but they do not fall in the distressed range based on the CSI-4.
Table 6
Relationship Satisfaction Scale Statistics
No. Items M SD a
KMSS 3 5.18 1.40 .97
CSI-4 4 17.30* 5.57* .98
SWMLS 5 4.53 1.82 .95
Note: Means represent averages of the items on that scale except for CSI-
4.
*CSI-4 mean represents the total score and standard deviation.
Marital Activities Profile (MAP) Scale & Aron Item
Please see Table 7 for additional validation measure scale statistics. The MAP Core
activity scale demonstrated low reliability (a = .60). Subsequent analyses using the MAP Core
scale should be cautiously interpreted. Participants reported, on average, weekly engagement in
activities that are common, every day, accessible, and frequently home-based. The MAP Balance
activity scale demonstrated adequate reliability (a > .70). Participants reported less frequency
engaging in Balance activities. Specifically, they reported approximately monthly engagement in
activities that typically provide a relatively novel experience, are not home-based, and that may
require more resources. This relative frequency is consistent with predicted patterns of such
leisure.
Although only one item from Arons scale (How exciting are the things you do with
your partner?) was used in subsequent analyses, as it was the only item out of the three items on
this scale that provided another assessment of frequency of exciting activities in the relationship,
27


the full Arons scale demonstrated good reliability (a = .80). Veterans reported approximately
moderate engagement in activities that were exciting with their partner.
Table 7
Additional Measure Scale Statistics
No. Items M SD a
MAP Core 7 3.02 .46 .60
MAP Balance 6 1.90 .44 .71
Aron 1 2.90 .93
Note: Means represent averages of the items on that scale.
Aim 1
PLAY Psychometrics
PLA Y Frequency Scales
Please see Table 8 for the PLAY frequency scale statistics. All of the frequency scales on
the PLAY measure demonstrated at least adequate internal consistency. Excellent reliability (i.e.,
a > .90) was found for the Novel and Exciting frequency PLAY scales. Adequate reliability (i.e.,
a > .70) was demonstrated for the overall frequency of PLAY scale. The Routine PLAY scale
initially had six items (routine, normal, unexciting, ordinary, mundane, predictable). Although
these items had adequate internal consistency (a = .77), I noted that two of the items (mundane
and unexciting) had relatively lower item-total correlations than the other items. Removing these
items actually improved the reliability (i.e., a = .81), even in the context of fewer items. I also
observed that these two items seemed more negatively valenced than the remaining words, which
appeared more neutral. I removed these items to compute a four item version of the scale. In
subsequent correlational analyses with both the six item and four item, I found the correlation
with the PLAY one item rating of monthly frequency of Routine PLAY stronger with the four
28


item measure. Thus, I felt that these two words may have detracted from the intent of the scale to
be a basic overview of frequency of the behavior, and incorporated more of the affective ratings
element into this scale. The four item measure seemed to be a better representation of the
intended construct and I used it for all remaining analyses.
Veterans in this sample are reporting an Overall Frequency of engaging in shared leisure
approximately two to three times a month. Veterans reported their average frequency of
engaging in Routine PLAY as often, Novel and Exciting PLAY a little. Paired samples t-
tests were conducted to compare frequency of routine, novel and exciting PLAY. There was a
significant difference for all comparisons. Specifically the results suggest that Veterans in this
sample more frequently participate in Routine PLAY as compared to Novel PLAY (t(67) =
11.30, p = .000). There was also a significant difference between frequency of Routine PLAY
and Exciting PLAY (t(67) = 10.26, p = .000). In addition, Veterans in this sample participate in
more Novel PLAY as compared to Exciting PLAY (t(67) = 4.36, p = .000).
Table 8
PLAY Frequency Scale Statistics
No. Items M SD a
PLAY
Overall Frequency 3 2.85 .94 .78
Routine Scale 4 3.87 .83 .81
Novel Scale 8 2.28 .82 .91
Exciting Scale 14 2.04 .82 .95
Note: Means represent averages of the items on that scale.
29


PLA Y Affect Scales
Excellent reliability (a > .94) was found for each of the positive and negative affect
scales for all three types of PLAY (Routine, Novel, Exciting). Please see Table 9 for the PLAY
Affect scale statistics.
In general, the participants reported feeling some positive affect during Routine PLAY,
and positive affect increased towards being rated as often during shared leisure that was Novel
and/or Exciting. On average, negative affect was reported as being experienced a little of the
time across all three types of PLAY (Routine, Novel, Exciting).
Table 9
PLAY Affect Scale Statistics
No. Items Mean SD a
PLAY Routine
Positive Affect 22 2.98 .96 .98
Negative Affect 25 1.99 .75 .95
PLAY Novel
Positive Affect 22 3.48 .97 .98
Negative Affect 25 1.98 .75 .96
PLAY Exciting
Positive Affect 22 3.70 1.03 .99
Negative Affect 25 1.76 .65 .94
Note: Means represent averages of the items on that scale.
Construct Validity of PLA Y
Construct validity of the PLAY measure was tested using a series of correlational
analyses. Each correlation served as an index of criterion validity. Please see Table 10 for an
30


overall table presenting these correlations. Each step in construct validity will be delineated in
detail below, in both narrative and table form.
Table 10
PLAY Frequency Correlations
Routine Item Novel Item Exciting Item Routine Scale Novel Scale Exciting Scale
Overall Frequency .76** g9** 34** .29* 64** .66**
Routine Item .50** 42** 46** .29* .31*
Novel Item g9** .22 64** .59**
Exciting Item .06 .66** .76**
Routine Scale .02 -.07
Novel Scale 34**
*p < .05; **p < .001
Note: Item refers to the one item of frequency, whereas Scale refers to the scale of
frequency.
Initially, most central to confirming validity of my PLAY measure is the degree to which
different measures of the same construct converge. Overall these measures converged. As an
initial test of criterion validity, the single items assessing frequency of types of PLAY were
shown to converge appropriately with their respective scale frequency of PLAY. For example,
the single-item assessment of monthly frequency of Routine PLAY correlated .46 (p < .001) with
the Routine scale of frequency. These single item assessments correlated with their respective
scales from .46 to .76 (see boldface values in Table 11).
31


Table 11
Correlations of Single Item and Scale PLAY Frequency
Routine Novel Exciting
Scale Scale Scale
Routine Item .46**
Novel Item .64**
Exciting Item .76**
*p < .05; **p < .001
Note: Item refers to the one item of frequency, whereas Scale refers to the
scale of frequency.
Although not central to confirming construct validity of my measure, it would also be
expected that greater frequency of novel PLAY should relate to greater frequency of
exciting PLAY given their theoretical overlap (per Balance activities in Johnson and
colleagues (2006) theory of Core and Balance). In fact, these do correlate significantly
regardless of whether they were asked in the scale or single item approach, with correlations
ranging from .59 to .84 (see boldface values in Table 12).
Table 12
Novel and Exciting PLAY Frequency Correlations
Exciting Novel Exciting
Item Scale Scale
Novel Item .69** .59**
Exciting Item .66** 76**
Novel Scale .84**
*p < .05; **p < .001
Note: Item refers to the one item of frequency, whereas Scale refers to the
scale of frequency.
Similarly, whereas not a part of validation of the measure, it is also interesting that other
aspects of PLAY frequency sometimes converged. For example, correlations also indicate that
32


the Routine Frequency Item (but not the Routine scale) was positively correlated with the
frequency of Novel and Exciting PLAY (both single item and scale; see boldface values in Table
13). Although this pattern was not consistent, there was some indication that more shared leisure
of one type is usually associated with more shared leisure of other types (as already evidenced by
the adequate internal consistency of the overall frequency PLAY scale). The only exception to
this were the correlations of the Routine scale with Novel or Exciting play (measured as a scale
or one item; see italicized values in Table 13).
Table 13
Correlations of PLAY Frequency
Routine Item Novel Item Exciting Item Routine Scale Novel Scale Exciting Scale
Routine Item .50** .42** 46** 29* .31*
Novel Item .22 64** .59**
Exciting Item .06 .66** .76**
Routine Scale .02 -.07
*p < .05; **p < .001
Note: Item refers to the one item of frequency, whereas Scale refers to the scale of
frequency.
Validation of PLAY Affect
Returning to the process of validation, in addition to the posited basic associations within
the PLAY measures of frequency, there are theoretically related patterns regarding affect during
PLAY. For example, one might posit that more positive affect regarding a specific type of play
will correlate with increased frequency of that specific type of PLAY. In general, this was
supported across all measurements of frequency of PLAY (i.e., Overall Frequency, single item,
and scale frequency), with one exception (see this exception in italicized font in Table 14)
33


wherein the Novel frequency single item did not significantly correlate with the Novel positive
affect scale).
Table 14
Positive Affect and Frequency of Same Type of PLAY
Routine Novel Exciting
Positive Positive Positive
Affect Affect Affect
Routine Item .29*
Routine Scale .25*
Novel Item .19
Novel Scale .53**
Exciting Item .38**
Exciting Scale .60**
*p < .05; **p < .01
Note: Item refers to the one item of frequency, whereas Scale refers to the
scale of frequency.
As a side note, it could be that positive affect during Routine PLAY (thus enjoying the
basic Core activities with a partner) would also be associated with higher levels of ones
participation in PLAY that is either Novel or Exciting with the partner (i.e., perhaps having fun
with the basic types of activities with the partner encourages more of the novel and exciting
activities with the partner). These associations were significant (see Table 15). In fact, positive
affect during novel and exciting play also predicted greater frequency of other types of play
(with the exception of the one item frequency of routine leisure).
34


Table 15
Positive Affect and Frequency of Different Types of PLAY
Routine Novel Exciting
Positive Positive Positive
Affect Affect Affect
Routine Item .10 .18
Routine Scale .28* .34**
Novel Item .46** .28*
Novel Scale .66** .56**
Exciting Item .49** .35**
Exciting Scale .63** .55**
*p < .05; **p < .01
Note: Item refers to the one item of frequency, whereas Scale refers to the
scale of frequency.
Similarly, just as positive affect regarding a specific type of activity should (and
generally did) predict greater reported frequency of that specific type of activity, one might
assume that more negative affect regarding a specific type of activity would correlate with less
frequency of that specific type of activity. However, there were no significant associations
between negative affect during specific types of PLAY and frequency of that respective type of
PLAY (see Table 16).
35


Table 16
Negative Affect and Frequency of Same Type of PLAY
Routine Novel Exciting
Negative Negative Negative
Affect Affect Affect
Routine Item -.12
Routine Scale -.04
Novel Item .14
Novel Scale .01
Exciting Item -.11
Exciting Scale -.13
*p < .05; **p < .01
Note: Item refers to the one item of frequency, whereas Scale refers to
the scale of frequency.
Likewise, one could assume that negative affect during any type of PLAY would
suppress frequency of participation in other types of PLAY. Interestingly, in general, this was
not supported. Only negative affect during Routine PLAY correlated with less frequency in both
Novel (r = -.26) and Exciting (r = -.29) type of PLAY (bothp < .05; please refer to items in
boldface in Table 17).
36


Table 17
Negative Affect and Frequency of Different Types of PLAY
Routine Negative Affect Novel Negative Affect Exciting Negative Affect
Routine Item -.01 -.04
Routine Scale -.08 -.03
Novel Item -.11 .02
Novel Scale -.26* -.05
Exciting Item -.24 -.02
Exciting Scale -.29* .01
*p < .05; **p < .01
Note: Item refers to the one item of frequency, whereas Scale refers to the
scale of frequency.
Thus, whereas the expected associations were found with positive affect predicting
frequency of PLAY, they were typically not found with negative affect predicting frequency of
PLAY.
An additional aspect of criterion validity is the level to which affective ratings are
associated with one another. We tested correlations among positive affect regarding different
types of PLAY (assumed to be positively correlated), correlations among negative affect
regarding different types of PLAY (assumed to be positively correlated), and correlations
between positive affect and negative affect regarding different types of PLAY (assumed to be
negatively correlated). In Table 18 it is shown that all instances of positive affect during PLAY
were positively correlated with each other, as would be expected. That is, one would predict that
positive emotional experience in one type of PLAY would be associated with positive emotional
experiences across all types of PLAY. This would also be expected of negative affect during
PLAY, and this was also found. Please see Table 19.
37


Table 18
Positive Affect Correlations
Novel Positive Affect Exciting Positive Affect
Routine Positive 72 ** .67**
Affect
Novel Positive
Affect
*p < .05; **p < .01
Table 19
Negative Affect Correlations
Novel Exciting
Negative Negative
Affect Affect
Routine Negative Affect .75** 54**
Novel Negative Affect .75**
*p < .05; **p < .01
Furthermore, one would expect that correlations between positive affect during each type
of PLAY and negative affect during each type of PLAY would be inversely correlated with one
another, respectively. In fact, this was found and is shown by boldface values in Table 20 below.
Similarly, one could extend this prediction such that positive affect during any type of PLAY
would be negatively correlated with negative affect across other types of PLAY. In general, this
was found with two exceptions when looking at positive affect during Routine PLAY and
negative affect in Novel and Exciting PLAY. However, the association between positive affect
during Routine PLAY and negative affect during Novel PLAY demonstrated a trend (p = .075),
thus with a larger sample size it is likely this would become significant.
38


Table 20
Positive and Negative Affect Correlations
Routine Novel Exciting
Negative Negative Negative
Affect Affect Affect
Routine Positive Affect -.52** -.22* -.13
Novel Positive Affect _ 42** -.43** _ 29**
Exciting Positive Affect _ 47** _ 29** -.45**
**p < .01; p is a trend (p = .075)
Taken together, the results from the correlations of positive and negative affect during all
types of PLAY provide more evidence regarding the validity of the affect measures.
Construct Validity of PLA Y Continued: Extension to Additional Measures
Additional correlational analyses were conducted assessing the relationship of PLAY
frequency items and scales with existing measures of theoretically similar constructs, specifically
the MAP and Arons question regarding engagement in exciting activities with the partner. It
was expected that frequency of Routine activities measured on the PLAY would correlate with
Core activities on the MAP. Similarly, it was predicted that frequency of both Novel and
Exciting PLAY would be correlated with Balance Activities on the MAP. Finally, it was
predicted that the frequency of Exciting PLAY would correlate with Arons question. These
associations are bolded in Table 21 and 22. As seen in those tables, there is support for these
hypothesized relationships, with 5 of the 6 being significant in the predicted direction, and the
sixth showing a trend (p = .06). That is, the PLAY Routine single-item frequency was not
associated with the MAP Core scale, as predicted, though it trended towards significance. As
noted in the Measure Reliabilities and Scale Statistics section above, the MAP Core scale
demonstrated lower internal consistency than all other scales, and thus may have limited the
39


validity of the scale as an overall measure of frequency of Core activities. Given the fact that the
PLAY Routine frequency item performed well in the most fundamental tests of criterion validity
noted above, this trend association with a measure of limited reliability is not seen as an
indication that the PLAY Routine frequency item is invalid.
Table 21
Frequency of PLAY and MAP Activities
MAP MAP
Core Balance
Routine Item -H co
Novel Item .50**
Exciting Item .50**
*p < .05; **p < .01; is a trend (p = .059).
Note: Item refers to the one item assessment of frequency.
On the other hand, Routine PLAY scale was significantly correlated with the MAP Core
scale. The MAP Balance scale was significantly correlated with the Novel and Exciting PLAY
scales, as expected. See Table 19 for PLAY frequency scales and MAP Activity correlations.
Table 22
PLAY Scales and MAP Activities Correlations
MAP MAP
Core Balance
Routine Scale .25*
Novel Scale .42**
Exciting Scale .51**
*p < .05; **p < .01
40


In regards to validating the PLAY measure against Arons question, results were found
that supported prior hypothesis. That is, the Exciting PLAY scale was correlated with Arons
single-item assessment of how exciting are the things you do with your partner (r = .25, p <
.05).
Whereas not central to the validation process of the PLAY measure, additional
correlational analyses with MAP Core and Balance and the PLAY frequency scales also
provided some interesting results. The Overall Frequency of PLAY was correlated with both
MAP Core and Balance. Moreover, frequency of MAP Core activities were not significantly
associated with Novel and Exciting PLAY frequency, with one exception where the MAP Core
activity frequency did correlate with single-item Novel frequency of PLAY (r = .31**,/) < .001;
see boldface value in Table 23). In regards to the MAP Balance activity frequency, there was a
significant association with the single item Routine frequency of PLAY, but not the Routine
scale frequency of PLAY (see Table 23).
Table 23
PLAY Frequency and MAP Activities
MAP MAP
Core Balance
Overall Frequency .30* .52**
Routine Item .27*
Routine Scale -.06
Novel Item .31**
Novel Scale .23
Exciting Item .20
Exciting Scale .09
*p < .05; **p < .01
In general, the results of Aim 1 suggest that the PLAY measure demonstrates
psychometric adequacy as a valid measure of frequency of and affect during shared leisure with
41


the partner, with the possible exception of the measurement of negative affect during PLAY.
First, validity assumptions seem to have been met for the frequency of specific types of activities
with other measures of the same type of activities, both as assessed within the PLAY measure
and with external measures of frequency of shared leisure (e.g., MAP Core and Balance, Arons
item).
Next, assessment of positive affect appeared to be valid in that there were generally
significant associations between positive affect during each type of PLAY (Routine, Novel,
Exciting) and increased frequency of the same types of PLAY (Routine, Novel, Exciting,
respectively). The one exception was between positive affect during Novel PLAY and the single-
item frequency of Novel PLAY. Positive affect during specific types of PLAY was also
consistently negatively correlated with negative affect during those specific types of PLAY.
Lastly, the findings with negative affect during PLAY were interesting. Contrary to
expectations, I did not find that negative affect during PLAY was associated with less frequent
PLAY (this will be deliberated further in the Discussion section of this document). However,
scales of negative affect during types of PLAY were strongly positively associated with each
other, and, as noted above, negative affect during specific types of PLAY was consistently
negatively correlated with positive affect during those specific types of PLAY. Thus, I consider
these results to provide tentative initial validation support for the negative affect scales.
Additional data will be presented later in the convergence and divergence of these scales with
measures of PTSD and relationship satisfaction, which will also inform the evaluation of validity
of the negative affect and other PLAY scales.
Thus, the PLAY measure appeared to have adequate reliability and validity to proceed
with the next aims.
42


Aim 2
Two correlation matrices are presented, Figure 1 is the predicted correlation matrix and
Figure 2 is the actual correlation matrix. Although some findings were as predicted, there were
no significant associations between PTSD and PLAY. There were also no significant
associations between PTSD and relationship satisfaction, with one exception, the PTSD
Avoidance symptom sub-cluster and relationship satisfaction as measured by the KMSS.
Associations between PTSD and relationship satisfaction, PTSD and PLAY, and PLAY and
relationship satisfaction are further described below.
43


PTSD Symptom Severity PTSD: Re-Experiencing Cluster PTSD: Emotional Numbing Cluster PTSD: Hyperarousal Cluster PLAY: Overall Frequency PLAY: Normal/Routine Frequency PLAY: New/Different Frequency PLAY: Exciting/Thrilling Frequency PLAY: Positive Affect During Normal/Routine Activities PLAY: Positive Affect During New/Different Activities PLAY: Positive Affect During Exciting/Thrilling Activities PLAY: Negative Affect During Normal/Routine Activities PLAY: Negative Affect During New/Different Activities PLAY: Negative Affect During Exciting/Thrilling Activities Relationship Satisfaction
PTSD Symptom Severity 1.00
PTSD: Re-Experiencing Cluster 1.00
PTSD: Emotional Numbing Cluster 1.00
PTSD: Hyperarousal Cluster 1.00
PLAY: Overall Frequency 1.00
PLAY: Normal/Routine Frequency 1.00
PLAY: New/Different Frequency 1.00
PLAY: Exciting/Thrilling Frequency 1.00
PLAY: Positive Affect During Normal/Routine Activities 1.00
PLAY: Positive Affect During New/Different Activities 1.00
PLAY: Positive Affect During Exciting/Thrilling Activities 1.00
PLAY: Negative Affect During Normal/Routine Activities 1.00
PLAY: Negative Affect During New/Different Activities 1.00
PLAY: Negative Affect During Exciting/Thrilling Activities 1.00
Relationship Satisfaction 1.00

-1.00 0 1.00
Figure 1. Predicted Correlation Matrix.
Note: Shading indicates the direction and magnitude of the correlation. Red shading indicates a negative correlation and blue shading indicates a positive correlation.
44


PTSD Symptom Severity PTSD: Re-Experiencing Cluster PTSD: Emotional Numbing Cluster PTSD: Hyperarousal Cluster PLAY: Overall Frequency PLAY: Normal/Routine Frequency PLAY: New/Different Frequency PLAY: Exciting/Thrilling Frequency PLAY: Positive Affect During Normal/Routine Activities PLAY: Positive Affect During New/Different Activities PLAY: Positive Affect During Exciting/Thrilling Activities PLAY: Negative Affect During Normal/Routine Activities PLAY: Negative Affect During New/Different Activities PLAY: Negative Affect During Exciting/Thrilling Activities Relationship Satisfaction
PTSD Symptom Severity 1.00 90** g9** 39** .08 .05 .10 .05 -.05 -.15 -.15 .18 .22 32** -.20
PTSD: Re-Experiencing Cluster 1.00 .69** 77** .13 .09 .14 .08 .02 -.12 -.09 .10 .20 32** -.08
PTSD: Emotional Numbing Cluster 1.00 .65** .04 .04 .01 .05 -.02 -.05 -.11 .15 .09 .25* U> o *
PTSD: Hyperarousal Cluster 1.00 .06 .03 .13 -.01 -.15 -.24 -.20 .25* .31* 32** -.13
PLAY: Overall Frequency 1.00 .76** 39** 34** 49** .26* .34** -.18 .05 -.05 32**
PLAY: Normal/Routine Frequency 1.00 .50** .42** .29* .10 .18 -.12 -.01 -.04 .18
PLAY: New/Different Frequency 1.00 .69** 44** .19 .28* -.11 .14 .02 .27*
PLAY: Exciting/Thrilling Frequency 1.00 49** .35** .38** -.24 -.02 -.11 .35**
PLAY: Positive Affect During Normal/Routine Activities 1.00 71** .67** _ 52** -.23 -.13 41**
PLAY: Positive Affect During New/Different Activities 1.00 37** -.43** -.43** _ 29** 32**
PLAY: Positive Affect During Exciting/Thrilling Activities 1.00 _ 47** _ 39** _ 45** 40**
PLAY: Negative Affect During Normal/Routine Activities 1.00 75** .64** -.31**
PLAY: Negative Affect During New/Different Activities 1.00 75** -.16
PLAY: Negative Affect During Exciting/Thrilling Activities 1.00 -.22
Relationship Satisfaction 1.00
* Correlation sig at 0.01 Correlation sig at 0.05 -1.00 0 1.00 I
-1.00 0 1.00
Figure 2. Actual Correlation Matrix
45


PTSD & Relationship Satisfaction
Surprisingly, in this sample, there were no significant associations between total PTSD
symptom severity and relationship satisfaction as measured by three distinct indices (KMSS,
CSI-4, SWMLS). Please see Table 24 for PTSD and Relationship Satisfaction correlations. This
was not an expected finding, as this relationship has been found repeatedly in prior literature. A
significant limitation of this study is the sample size. Two of the correlations with the Total score
were in the moderate range (e.g., -.20) but were not significant in this sample. Therefore, I may
have not had enough power to detect smaller effects. In other studies evaluating links between
PTSD and marital satisfaction, there has been variability in the magnitude of this association. For
example, Taft et al.s (2011) meta-analysis reported that PTSD was related to intimate
relationship discord, but that the range of correlations in various studies was .11 to .73, with a
medium true score correlation (p) of .38. This is similar to other studies not included in the meta-
analysis by Taft and colleagues (2011), that have found modest to moderate associations between
PTSD and marital satisfaction, including correlations from -.31 (Miller, Schaefer, Renshaw, &
Blais, 2013), to -.39 (Meis et al., 2010), and -.48 (Renshaw, Rodrigues, & Jones, 2009). This
will be considered in more detail in the Discussion. When looking at sub-clusters, the only
significant correlation was found between the PTSD Avoidance symptom cluster and the KMSS
(.r = -.30, p = .01; see boldface value in Table 24).
46


Table 24
PTSD & Relationship Satisfaction Correlations
KMSS CSI-4 SWMLS
PCL-C
Total Symptom Severity -.20 -.10 -.20
Re-Experiencing -.08 -.05 -.13
Avoidance -.30* -.10 -.18
Hyperarousal -.13 -.12 -.23*
*p < .05; -p is a trend (p = .06)
PTSD & PLAY
Contrary to hypotheses, there were no significant findings between total PTSD symptom
severity and/or sub-clusters of PTSD symptoms and (1) single-item frequency of PLAY (that is,
Routine, Novel, or Exciting) or (2) PLAY frequency scales. See Table 25 for PTSD and PLAY
frequency correlations.
Table 25
PTSD & PLAY Frequency Correlations
PLAY Overall Frequency Routine Item Routine Scale Novel Item Novel Scale Exciting Item Exciting Scale
PCL-C Total Symptom .08 .05 01 .10 -.06 .05 -.04
Severity
Re- .13 .09 -.03 .14 .00 .08 .04
Experiencing
Avoidance .04 .04 .01 .01 -.09 .05 -.09
Hyperarousal .06 .03 .04 .13 -.07 -.01 -.05
Note: Item refers to the one item of frequency, whereas Scale refers to the scale of
frequency.
47


Non-significant findings also occurred between the PTSD variables and types of leisure
activities as assessed by the MAP. That is, Core and Balance activities were not significantly
correlated with PTSD symptoms.
In examining PTSD and the emotion scales of PLAY, the direction of correlations were
generally consistent with predictions (i.e., PTSD symptoms associated with less positive affect
and more negative affect during play), but the magnitude and significance of these associations
varied considerably. Negative affect during Exciting PLAY was significantly correlated with all
aspects of PTSD. The Hyperarousal cluster of PTSD symptoms was also significantly positively
correlated with negative affect during Routine and Novel types of PLAY. See Table 26 for PTSD
and PLAY Affect correlations, where significant correlations are shown in boldface.
48


Table 26
PTSD and PLAY Affect Correlations
PLAY Routine PLAY Novel PLAY Exciting
Positive Affect Negative Affect Positive Affect Negative Affect Positive Affect Negative Affect
PCL-C
Total Symptom Severity -.05 .18 -.15 _ A .22 -.15 .32**
Re-Experiencing Cluster .02 .10 -.12 .20 -.09 .32**
Avoidance Cluster -.02 .15 -.05 .09 -.11 .25*
Hyperarousal Cluster -.15 .25* -.24 .31* -.20 .32**
*p = .01; **p < .001; -p is a trend (p = .055); Ap is a trend (p = .080).
49


PLAY & Relationship Satisfaction
Overall, the majority of the PLAY frequency variables were significantly correlated with
all measures of relationship satisfaction (Table 27). There were only non-significant findings
between the single-item frequency and scale frequency of Routine PLAY and the KMSS (see
italicized values in Table 27).
Table 27
PLAY Frequency & Relationship Satisfaction Correlations
KMSS CSI-4 SWMLS
PLAY
Overall Frequency 32** .60** .54**
Routine Item .18 40** 42**
Routine Scale .16 .30* 32**
Novel Item 21* .54** .45**
Novel Scale .38** .66** .57**
Exciting Item .35** .56** 48**
Exciting Scale 42 ** .59** 47**
*p = .01; **p < .001.
Note: Item refers to the one item of frequency, whereas Scale refers to the scale of
frequency.
50


PLAY Affect & Relationship Satisfaction
Positive affect across all types of PLAY were significantly correlated with all measures
of relationship satisfaction (Table 28). Negative affect showed a less consistent pattern with
relationship satisfaction. Negative affect during Routine PLAY was significantly associated with
all measures of relationship satisfaction, and in the correct direction. That is, as negative affect
during Routine PLAY increased, relationship satisfaction decreased. However, negative affect
during Novel and Exciting PLAY was not significantly correlated with relationship satisfaction
with one exception (negative affect during Novel PLAY was negatively correlated with the
SWMLS, r = -32, p < .001).
Table 28
PLAY Affect and Relationship Satisfaction Correlations
KMSS CSI-4 SWMLS
PLAY Routine
Positive Affect 42 ** 24** 20**
Negative Affect -.31** . 51** . 51**
Novel
Positive Affect 32** .53** .53**
Negative Affect -.16 -.20 32**
Exciting
Positive Affect 40** .59** .57**
Negative Affect -.22 -.19 -.24
*p = .01; **p < .001; -p is a trend (.08)
51


Aim 3
Due to the lack of significant correlations found between PTSD variables and relationship
satisfaction, I was unable to test the mediation models as previously planned. Although there
exists one significant association between PTSD Avoidance symptom sub-cluster and
relationship satisfaction as measured by the KMSS, given the isolated nature of this finding, it
may be Type I error in this sample. That is, it was not consistent with the general pattern of
findings in the sample. Thus, no tests of mediation were conducted.
52


CHAPTER V
DISCUSSION
The purpose of this study was to thoroughly explore the associations between PTSD,
relationship satisfaction, and shared leisure activities with the partner in OEF/OIF Veterans. In
addition, this study uniquely contributed to the design and validation of a measure to assess both
frequency and affective experience of different types of shared leisure activities. To my
knowledge, this is the first study to explore these constructs with detailed specificity.
PLAY Psychometric Properties
In general, the results of this study demonstrate that the pilot measure tested in this
sample is a reliable and valid measure of shared leisure activity. Specifically, internal
consistency ranged from adequate to excellent reliability for both frequency and affective
experience of PLAY. Construct validity of the frequency of shared leisure items was
demonstrated by significant correlations both within and across specific types of leisure that
were defined as Routine, Novel and Exciting as assessed by both single-item frequency and scale
frequency. Not only did frequency of these types of leisure demonstrate validity within the same
measure of PLAY, it was also correlated in the predicted manner with external measures of
leisure (e.g., Core and Balance). The fact that the reported frequency of Routine PLAY was
significantly less than Novel and Exciting PLAY also supports the validity of these scales, as this
was the expected pattern.
Interesting findings occurred during validation of the affective experience during types of
PLAY scales. Positive affect during all three types of PLAY generally demonstrated the
predicted associations thought to support validity for these scales; that is, positive affect during
PLAY was correlated with increased frequency of that type of PLAY (with one exception
53


between positive affect during Novel PLAY and Novel PLAY assessed by the single-item
frequency), positive affect during a specific type of play was inversely related with negative
affect during that type of play, and positive affect during PLAY was consistently positively
associated with relationship satisfaction. There were some unexpected findings (e.g., positive
affect did not relate to PTSD), but the overall pattern suggests that the positive affect scales were
valid.
Whereas the positive affect during PLAY scales appear valid, I found relatively more
unpredicted results regarding negative affect experienced during PLAY. That is, none of the
negative affect scales during all three types of PLAY correlated with less frequency of that
respective type of PLAY. It is unclear as to why there were no significant associations between
negative affect and reduced frequency of PLAY. However, negative affect during specific types
of PLAY was consistently negatively correlated with positive affect during those specific types
of PLAY. Moreover, I found that PTSD and all the PTSD symptom sub-clusters were correlated
with negative affect during Exciting PLAY. Negative affect during Routine and Novel PLAY
was also correlated in the right direction with the PTSD Hyperarousal symptom sub-cluster. One
would expect that negative affect would increase during PLAY as PTSD symptoms increase,
thus my findings show a pattern here that provides some confirmation that the negative affect
scale may be a valid scale. In addition, negative affect during Routine PLAY was inversely
associated with relationship satisfaction. This would be expected, such that if an individual is
experiencing negative emotions during the typical shared leisure, they are less likely to enjoy
their relationship. Here again is an interesting finding in that this was only significant for Routine
PLAY. Negative affect during Novel and Exciting PLAY did not demonstrate associations with
the primary measure of relationship satisfaction, although negative affect during Exciting PLAY
54


may be demonstrating a trend toward significance with relationship satisfaction. It could be that
with a larger sample size, negative affect would demonstrate significant inverse associations.
Due to these additional analyses, I tentatively consider the negative affect scales on the
PLAY measure to be valid. It would be beneficial for future studies to administer the PLAY
measure and assess validation of the negative affect scale in larger samples, either to explore
additional patterns and/or to have the power to conduct a factor analysis. It could be that negative
affect is more nuanced than was previously theorized, particularly in a population with
symptoms of PTSD. For instance, there could be multiple categories of negative affect, such as
differentiating between sad and angry or hypervigiliant. Moreover, certain adjectives
thought to be positive such as exciting, may actually be negative for a population with
symptoms such as hypervigilance. Administering the PLAY measure to a larger sample would
provide the necessary power to conduct a factor analysis and determine if these differences in
negative affect exist.
Interrelationships between PTSD, PLAY & Relationship Satisfaction
Interesting findings emerged from conducting analyses on the interrelationships among
PTSD, PLAY and relationship satisfaction as well as examining specific components of these
variables (i.e., PTSD symptom clusters, frequency of PLAY, affect during PLAY). Some
unexpected findings emerged, such as a general lack of association between PTSD and the
measures of relationship satisfaction or leisure. When considering these findings, an
understanding of this samples demographic characteristic may be beneficial. On average, this
sample is reporting high levels of PTSD, including total symptom severity and at the symptom
cluster level. Veterans also are endorsing some dissatisfaction with their relationship, in fact,
with the average of 5.18 on the KMSS, this sample fell below the cutoff criteria of a score of
55


5.67 on the KMSS as recommended by Crane and colleagues (2000), where below 5.67 would be
considered distressed. This sample did report participating in shared leisure with their partner,
and on somewhat expected levels of more frequency of shared leisure that was routine, normal
and home-based day-to-day activities compared to less frequency of shared leisure that was
considered exciting, new, and not home-based. As there are no norms for these shared leisure
measures, it is unknown whether the observed frequency of shared leisure represents typical or
divergent levels compared to other samples.
Given these general levels of PTSD and relationship satisfaction, it is unclear why PTSD
did not generally correlate with relationship satisfaction; that is, there did appear to be adequate
variability on the constructs such that an association would not be constrained by issues such as
uniformly high satisfaction or low PTSD. One possibility is that, due to the fact that the Veterans
in this study were recruited and included into the study because they were all receiving mental
and/or physical health care at a VA setting, perhaps these Veterans have learned strategies to
cope with the impact of PTSD on their relationship functioning. Of course, one issue affecting
the fact that PTSD and relationship satisfaction did not significantly correlate is limited power.
The magnitude of correlations was, at times, moderate, which is consistent with prior literature
that has found correlations from 11 to .73 (Taft et al., 2011), though is lower than more recent
magnitude of correlations reported between -.31 (Miller et al., 2013) and -.48 (Renshaw et al.,
2009). One significant inverse correlation was found between PTSD Avoidance symptom cluster
and one of the measures of relationship satisfaction (the KMSS). Avoidance has prior research
support as one of the more potent predictors of relationship distress (Riggs et al., 1998). A more
recent study reported that the avoidance symptoms showed the strongest association with general
56


functional impairment, an intermediate association with hyper-arousal symptoms, and the lowest
association with re-experiencing symptoms (Rona et al., 2009), which is similar to my results.
In addition to the unexpected results for PTSD and relationship satisfaction, I also did not
find any significant correlations between PTSD and PLAY frequency. This was contradictory to
my hypotheses that as PTSD symptoms increase, one would engage in less frequency of shared
leisure with their partner. In examining the values of the correlations, it does not appear that this
is a limitation of a small sample size, as the magnitude of all the correlations was nil to small. It
could be that these Veterans, who are engaged with the VA and able to participate in research,
are not significantly impacted by their PTSD such that it does not interfere with their day-to-day
functioning or engagement in activities with the partner. Another possible explanation that may
warrant future investigation is looking at categorizing these Veterans into subtypes. For
example, there may be Veterans with PTSD who are seeking more PLAY, in order to escape
negative affect or a need to re-create the combat rush experience (Grigsby, 1991) and pursue
more dangerous, thrilling activities. In addition, these Veterans that pursue more exciting
activities that may include elements of danger may engage in these activities by themselves or
with military and/or civilian buddies as compared to their romantic partners. There may be a
category of Veterans that are more avoidant of play, perhaps because engaging in activities
because participation in activities amplifies their symptoms of PTSD (e.g., startle response,
anger, detachment) or they feel depression and anhedonia which suppresses their desire to
engage in leisure. Although these subtypes have not been verified, they do correspond with
qualitative analyses I conducted with a subset of the participants in this sample (Betthauser,
Allen, Grigsby & Brenner, under review). Thus, the overall lack of findings may obscure two
underlying subtypes where some Veterans show positive associations between PTSD and PLAY
57


with the partner, and others show negative associations between PTSD and PLAY with the
partner. It should be noted that in these qualitative analyses, thrilling play was usually either
engaged in as an individual pursuit or with their military and civilian buddies, with less
participation of this type of play shared with their partner. Thus, it is likely that the frequency of
play reported in this study is not an accurate representation of the actual frequency of these
Veterans leisure, as I asked them only to report on shared leisure with the partner. In any case,
future research may better identify such subtypes of differential associations between PTSD and
play.
When examining the relationship between PTSD and affect during PLAY, there emerged
more, and interesting, significant patterns. First, as PTSD symptoms (measured by total symptom
severity and each symptom sub-cluster) increased, the experience of negative affect during
Exciting PLAY increased. Second, as PTSD Hyperarousal symptoms increased, so did negative
affect during all three types of PLAY. Although frequency of PLAY is not inhibited by PTSD
symptoms in this sample, assessing the association between negative affect and PLAY is
important. This makes sense, considering the manifestation of PTSD symptoms such as
numbing, anger, and irritability may increase when exposed to situations that activate their
behavioral response or negative cognitions that remind them of a traumatic event. Considering
that the question asked was about leisure that is exciting or thrilling this may have brought to
mind activities such as dangerous activities or activities that include crowds or loud noises,
which in turn would exacerbate PTSD symptoms of avoidance and hyperarousal. Clinically, this
information is relevant, as a focus of therapy may be on collaborating with the Veteran on coping
techniques for the specific symptoms and/or on coping techniques during activities that may be
considered too exciting. Educating the partner about potential increases in negative affect
58


during PLAY and PTSD symptoms may help the couple to explore activities in a safe manner
and promote problem-solving or coping techniques when faced with such situations that may
increase PTSD symptoms or negative affect.
Results from this study did show that participation in shared leisure is associated with
greater relationship satisfaction. This is consistent with Aron and colleagues (2001) self-
expansion theory as applied to couples and Johnson and colleagues (2006) theory of Core and
Balance leisure in couples. These findings of significant associations between Novel and
Exciting PLAY and relationship satisfaction should be carefully considered with the findings that
negative affect during Exciting PLAY is more likely to be reported when PTSD symptoms are
higher, and that Hyperarousal predicts negative affect during all types of PLAY. Specifically, if
recommending increased leisure for populations that may have experienced trauma, one should
prepare the couple with coping and/or problem-solving techniques for managing negative affect
during leisure that may exacerbate PTSD symptoms. In this way, the couple may further benefit
from engaging in safe, shared leisure in a manner that can promote relationship functioning
while mitigating negative outcomes.
We know from cognitive behavioral therapy and couples therapy techniques that
behavioral activation is a key component of addressing dysfunctional symptoms. Thus, carefully
considering types of PLAY, promoting frequency, and providing strategies around the affective
experience of PLAY may assist the Veteran and their partners in employing more constructive
activation and connection strategies in naturalistic settings that could help with PTSD symptoms
and relationship adjustment.
59


CHAPTER VI
LIMITATIONS
The most significant limitation of this study was the small sample size. As such, I was
limited in conducting additional scale development techniques, such as factor analysis.
Administration of the PLAY measure to a diverse and larger sample size would likely assist in
more sophisticated scale development. This may also address the validation concern regarding
the negative affect scales and provide greater understanding of how negative affect correlated
with shared leisure in romantic relationships.
Because the PLAY measure was developed with the idea to assess PTSD, PLAY and
relationship satisfaction in the OEF/OIF Veteran population, there are limitations to generalizing
these findings to other cohorts of Veterans and/or the general population. Additional
psychometric testing of this measure in diverse populations would provide greater external
validity of this measure.
The limitation of sample size also inhibited my power to detect significant associations
between PTSD and relationship satisfaction that may emerge in a larger sample. At the same
time, I considered the sample demographics and responses on measures and analyses showed
that there was good variability around responses on PTSD and relationship measures.
Another limitation of this study was that all the data were collected at one-time point.
This precluded my ability to assess the temporal sequencing of PTSD, shared leisure activity,
and relationship satisfaction. It is likely that the association between shared leisure activities,
PTSD, and relationship satisfaction are cyclical, with these variables influencing each other.
60


Since only the OEF/OIF Veteran completed the study procedures, I am lacking data from
the Veterans significant other; thus limiting my ability to interpret the findings as a
representation of the couple.
61


CHAPTER VII
CONCLUSIONS & IMPLICATIONS
This study provided an in-depth examination of the associations between clinically
relevant issues (i.e., PTSD, relationship satisfaction) and shared leisure, for Veterans returning
home from Afghanistan and Iraq. Research has demonstrated that reintegration into close
interpersonal relationships for these combat Veterans is difficult (McNulty, 2005). Veterans have
reported that these reintegration issues are as important or even more important that resolving
psychiatric symptoms (Johnson, Rosenheck, Fontana, et al., 1996; Zatzick, Russo, Rajotte, et al.,
2007). Thus, family therapy or couple conjoint therapy techniques addressing reintegration
should be useful. The current study provides some support for the notion that including elements
of promoting shared leisure activities within such interventions may serve to increase the
Veterans relationship adjustment with the caveats noted above regarding affect during such
activities. Future studies may expand upon our understanding of the interrelationships PTSD,
PLAY and relationship satisfaction by including larger and more diverse samples, qualitative
elements, possible moderators of associations, partner data, and additional measures of
psychosocial functioning.
62


REFERENCES
Allen, E.S., Rhoades, G.K., Stanley, S.M., & Markman, H.J. (2010). Hitting home: Relationships
between recent deployment, posttraumatic stress symptoms, and marital functioning for
Army couples. Journal of Family Psychology, 24, 280-288.
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APPENDIX
72


APPENDIX A
PLAY MEASURE
73


1. How often do vou do activities with your partner?
Response: Not at all (1) A little (2) Some (3) Often (4) Very often (5)
FUN
EXCITING
DIFFERENT
NEW
EXTREME
OUT OF THE ORDINARY
ROUTINE
TEDIOUS
STIMULATING
CHALLENGING
ADVENTUROUS
NORMAL
UNFAMILIAR
ARTISTIC
UNEXCITING
AMUSING
FRESH/ORIGINAL
SUBDUED
UNUSUAL
ENJOYABLE
CAREFREE
PEACEFUL
Response: Not at all (1) A little (2) Some (3) Often (4) Very often (5)
ADRENALINE PUMPING
HEART RACING
BORING
RISKY
AROUSING
PLEASURABLE
NOVEL
PLAYFUL
INTERESTING
EXPLORATORY
CREATIVE
BOLD
ORDINARY
ACTIVATING
MUNDANE
EXHILARATING
SILLY
PREDICTABLE
SHOCKING
DARING
RELAXING
UNPLEASURABLE
REWARDING
MISCHIEVOUS


2. When you do new, different activities with your partner, how often do you feel:
Response: Not at all (1) A little (2) Some (3) Often (4) Very often (5)
JOY
HAPPINESS
LOVE
SADNESS
ANGER
FRUSTRATION
EXCITED
STIMULATED
SCARED
ANNOYED
PLEASURE
CONTENTMENT
ANXIOUS
OPTIMISTIC
PESSIMISTIC
FEAR
DISGUST
MOTIVATED
THE NEED TO ESCAPE
AMUSEMENT
NOTHING
Response: Not at all (1) A little (2) Some (3) Often (4) Very often (5)
GIDDY
BORED
STRESSED
NEUTRAL
UNCOMFORTABLE
COMFORTABLE
INTERESTED
HOPE
DISINTERESTED
GOOD
BAD
CONFIDENT
INDIFFERENCE
DETACHED
RESTRICTED
MISERABLE
SATISFIED
DISSATISFIED
ALIVE
WONDERFUL
THE NEED TO LAUGH
75


LIKE YOU WANT TO SMILE
JITTERY
NUMB
2. When you do new, different activities with your partner, how often do you feel:
Response: Not at all (1) A little (2) Some (3) Often (4) Very often (5)
JUMPY
IN HIGH SPIRITS
ON EDGE
CHEERFUL
PANICKY
EMPTY
76


3. When you participate in normal, routine leisure activities with your partner, how often do you feel:
Response: Not at all (1) A little (2) Some (3) Often (4) Very often (5)
JOY
HAPPINESS
LOVE
SADNESS
ANGER
FRUSTRATION
EXCITED
STIMULATED
SCARED
ANNOYED
PLEASURE
CONTENTMENT
ANXIOUS
OPTIMISTIC
PESSIMISTIC
FEAR
DISGUST
MOTIVATED
THE NEED TO ESCAPE


Response: Not at all (1) A little (2) Some (3) Often (4) Very often (5)
AMUSEMENT
NOTHING
GIDDY
BORED
STRESSED
NEUTRAL
UNCOMFORTABLE
COMFORTABLE
INTERESTED
HOPE
DISINTERESTED
GOOD
BAD
CONFIDENT
INDIFFERENCE
DETACHED
RESTRICTED
MISERABLE
SATISFIED
DISSATISFIED
ALIVE
WONDERFUL
77


THE NEED TO LAUGH
LIKE YOU WANT TO SMILE

3. When you participate in normal, routine leisure activities with your partner, how often do you feel:
Response: Not at all (1) A little (2) Some (3) Often (4) Very often (5)
JITTERY
NUMB
JUMPY
IN HIGH SPIRITS
ON EDGE
CHEERFUL
PANICKY
EMPTY
78


4. When you participate in exciting or thrilling activities with your partner, how often do you feel:
Response: Not at all (1) A little (2) Some (3) Often (4) Very often (5)
JOY
HAPPINESS
LOVE
SADNESS
ANGER
FRUSTRATION
EXCITED
STIMULATED
SCARED
ANNOYED
PLEASURE
CONTENTMENT
ANXIOUS
OPTIMISTIC
PESSIMISTIC
FEAR
DISGUST
MOTIVATED
THE NEED TO ESCAPE
AMUSEMENT
NOTHING

Response: Not at all (1) A little (2) Some (3) Often (4) Very often (5)
GIDDY
BORED
STRESSED
NEUTRAL
UNCOMFORTABLE
COMFORTABLE
INTERESTED
HOPE
DISINTERESTED
GOOD
BAD
CONFIDENT
INDIFFERENCE
DETACHED
RESTRICTED
MISERABLE
SATISFIED
DISSATISFIED
ALIVE
WONDERFUL
THE NEED TO LAUGH
LIKE YOU WANT TO SMILE
79


JITTERY
NUMB

4. When you participate in exciting or thrilling activities with your partner, how often do you feel:
Response: Not at all (1) A little (2) Some (3) Often (4) Very often (5)
JUMPY
IN HIGH SPIRITS
ON EDGE
CHEERFUL
PANICKY
EMPTY
80


APPENDIX B
PLAY SCALES
Positive Leisure Activities with You Measure Scales
Activities Scales (Item 1: How often do you do___activities with your partner?)
NORMAL/ROUTINE NEW/DIFFERENT EXCITING/THRILLING
Routine Different Exciting
Normal New Extreme
Unexciting Out of the Ordinary Stimulating
Ordinary Unfamiliar Adventurous
Mundane Fresh/Original Adrenaline-Pumping
Predictable Unusual Heart-racing
Novel Risky
Exploratory Arousing
Bold
Activating
Exhilarating
Shocking
Daring
Mischievous
81


ADDITIONAL WORDS (do not predict loading on scales above)
Fun Tedious
Challenging Artistic
Amusing Subdued
Enjoyable Carefree
Peaceful Boring
Pleasurable Playful
Interesting Creative
Silly Relaxing
Unpleasurable Rewarding
Affect Scales (Items 2-4: When you do [new/different; normal/routine; exciting/thrilling
activities] with your partner, how often do you feel)
POSITIVE EMOTION NEGATIVE EMOTION
Joy Sadness
Happiness Anger
Love Frustration
Excited Scared
Stimulated Annoyed
Pleasure Anxious
Contentment Pessimistic
Optimistic Fear
Motivated Disgust
Amusement Need to escape
82


Giddy Bored
Interested Stressed
Hope Uncomfortable
Good Disinterested
Confident Bad
Satisfied Detached
Alive Restricted
Wonderful Miserable
Need to laugh Dissatisfied
Like you want to smile Jittery
In high spirits On edge
Cheerful Jumpy
Numb
Panicky
Empty
ADDITIONAL WORDS
Nothing
Neutral
Indifference
83


APPENDIX C
PREDICTED CORRELATION MATRIX
84


PTSD Symptom Severity PTSD: Re-Experiencing Cluster PTSD: Emotional Numbing Cluster PTSD: Hyperarousal Cluster PLAY: Overall Frequency PLAY: Normal/Routine Frequency PLAY: New/Different Frequency PLAY: Exciting/Thrilling Frequency PLAY: Positive Affect During Normal/Routine Activities PLAY: Positive Affect During New/Different Activities PLAY: Positive Affect During Exciting/Thrilling Activities PLAY: Negative Affect During Normal/Routine Activities PLAY: Negative Affect During New/Different Activities PLAY: Negative Affect During Exciting/Thrilling Activities Relationship Satisfaction
PTSD Symptom Severity LOO
PTSD: Re-Experiencing Cluster LOO
PTSD: Emotional Numb m2 Cluster LOO
PTSD: Hyperarousal Cluster LOO
PLAY: Overall Frequency LOO
PLAY: Normal/Routine Frequency LOO
PLAY: New/Different Frequency LOO
PLAY: Exciting/Thrilling Frequency LOO
PLAY: Positive Affect During Normal/Routine Activities LOO
PLAY: Positive Affect During New/Different Activities 1.00
PLAY: Positive Affect During Exciting/Thrilling Activities 1.00
PLAY: Negative Affect During Normal/Routine Activities 1.00
PLAY: Negative Affect During New/Different Activities 1.00
PLAY: Negative Affect During Exciting/Thrilling Activities 1.00
Relationship Satisfaction 1.00

-1.00 0 1.00
85


APPENDIX D
MEDIATION FIGURE
Step 1: Conduct a correlation to establish a significant association between PTSD symptom
severity and Relationship Satisfaction.
PTSD Symptom Severity-
> Relationship Satisfaction
c
Step 2: Conduct a correlation to establish a significant association between PTSD symptom
severity and PLAY.
Relationship Satisfaction
Step 3: Conduct a regression using PTSD symptom severity and PLAY simultaneously to
establish PLAY as a significant predictor variable to the outcome variable of Relationship
Satisfaction (controlling for PTSD).
PLAY*
PTSD Symptom Severity
Relationship Satisfaction
86


Step 4: Based on Step 3 regression equation, assess the effect of PTSD symptom severity on
Relationship Satisfaction, controlling for PLAY (path c). Degree of change from c to c will be
described. The indirect effects accounted for by PLAY will be estimated using Kenny (2009).
PLAY*
Relationship Satisfaction
c'
*PLAY variables will change for each mediation analyses. See below:
Mediation 1: PLAY =
Mediation 2: PLAY =
Mediation 3: PLAY =
Mediation 4: PLAY =
Mediation 5: PLAY =
Mediation 6: PLAY =
Mediation 7: PLAY =
Mediation 8: PLAY =
Mediation 9: PLAY =
Mediation 10: PLAY
Overall frequency of PLAY
Normal/routine frequency of PLAY
New/different frequency of PLAY
Exciting/thrilling frequency of PLAY
Positive affect during Normal/routine PLAY
Positive affect during New/different PLAY
Positive Affect during Exciting/thrilling PLAY
Negative affect during Normal/routine PLAY
Negative affect during New/different PLAY
= Negative Affect during Exciting/thrilling PLAY
87


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