Disorder-specific couple therapy
Cognitive-Behavioral Conjoint Therapy for PTSD (CBCT for PTSD)
15-session dyadic intervention targeting relationship satisfaction and PTSD symptoms. Composed of three phases: (1) psychoeducation and safety building; (2) dyadic skill-building, including communication and in vivo-graded exposures; and (3) trauma-focused cognitive interventions
Strategic Approach Therapy (SAT)
10-session couple therapy consisting of three phases: (1) motivational enhancement and psychoeducation, (2) relationship enhancement, and (3) partner-assisted exposures
A sample of six couples found improvement in avoidance and numbing symptoms of PTSD. Relationship adjustment outcomes not reported (Sautter et al. 2009)
Emotionally Focused Couple Therapy for PTSD (EFCT for PTSD)
12–20 session couple therapy focusing on identifying and understanding trauma-associated emotions. Composed of three phases: (1) identifying negative interactions, (2) dyadic skill-building including acceptance and communication, and (3) interactional and coping strategies
Two case studies and one case study replication with 10 couples have found improvements in relationship satisfaction and PTSD symptoms (Greenman and Johnson 2012; Johnson 2002; MacIntosh and Johnson 2008). Several cases of increased emotional abuse were noted, however, in couples where abuse was already present (MacIntosh and Johnson 2008)
Lifestyle Management Course
Five-day group residential program for Australian veterans and partners. Wide range of topics covered, including psychoeducation, self-care, problem-solving, and stress management
Gains in veterans’ PTSD symptoms at post-intervention were not maintained at 6-month follow-up. Sustained reductions in depression, anxiety, and stress. No improvement in relationship satisfaction (Devilly 2002)
Generic couple therapy
Behavioral Couple/Family Therapy (BC/FT)
Behavioral interventions used to improve communication skills and problem-solving
In a randomized controlled trial with BFT following individual exposure therapy versus individual exposure therapy alone revealed greater improvement in problem-solving with BFT. No additional gains in PTSD symptoms with BFT (Glynn et al. 1999). Likewise, uncontrolled trials reveal some improvement in relationship functioning but not PTSD symptoms (Cahoon 1984; Sweany 1987)
Month-long intensive treatment program for Israeli veterans with PTSD. Some spousal involvement. Program includes psychoeducation, communication skills, and problem-solving
Education and family facilitated engagement
Support and Family Education program (SAFE)
14-session educational program for family members of veterans with mental health difficulties. Workshop sessions include topics such as psychoeducation, skills training, problem-solving, and stress reduction
Few outcomes reported. Program evaluation noted very high participant satisfaction, and participation led to better understanding of mental health difficulties, awareness of resources, and engagement in self-care (Sherman 2003)
Reaching Out to Educate and Assist Caring, Healthy Families program (REACH)
16-session psychoeducation program for veterans and family members. Three phases included goal-setting and rapport building, psychoeducation, and maintenance of gains
Few outcomes reported. Program evaluation noted high program retention and high participant satisfaction ratings (Sherman et al. 2011)
Coaching into Care program
A telephone intervention available to family members of US veterans providing guidance to encourage veterans to access mental health services
Reports indicate some increase in veteran health-care service use after family members have used the program (Sayers et al. 2011)
24.2.1 Disorder-Specific Couple Therapy
Three types of disorder-specific couple therapy for PTSD have been examined thus far in the literature.
22.214.171.124 Cognitive-Behavioral Conjoint Therapy for PTSD
Cognitive-Behavioral Conjoint Therapy for PTSD (CBCT for PTSD) is a 15-session conjoint therapy designed to reduce PTSD symptoms and enhance relationship satisfaction. The therapy consists of three phases: (1) psychoeducation about PTSD and safety building; (2) dyadic skill-building, specifically focusing on communication skills and graded in vivo approach assignments to reduce avoidance and increase mutually satisfying activities for the dyads; and (3) trauma-specific cognitive interventions to address problematic trauma appraisals and beliefs maintaining PTSD and relationship problems. CBCT for PTSD has been tested in three uncontrolled studies with Vietnam veterans, Iraq/Afghanistan veterans, and community members, as well as a wait-list controlled trial (Monson et al. 2004, 2011, 2012a; Schumm et al. 2013). All four studies have revealed significant improvements in PTSD symptoms as well as increased relationship satisfaction, even when couples do not begin treatment relationally distressed. In addition, intimate partners participating in CBCT for PTSD showed evidence of improvements in their psychological functioning (Monson et al. 2005; Shnaider et al. 2014).
126.96.36.199 Strategic Approach Therapy
Strategic Approach Therapy (SAT) is a 10-session behavioral couple therapy that specifically targets avoidance and numbing symptoms of PTSD. The treatment consists of three phases: (1) motivational enhancement and psychoeducation about PTSD (focusing on avoidance symptoms in particular), (2) relationship enhancement and increased emotional intimacy, and (3) partner-assisted graded exposures for anxiety reduction. One study presenting findings from six couples (all heterosexual couples with male military veteran partners with PTSD) noted significant improvements in overall PTSD symptoms by patient, partner, and clinician ratings, but no reductions in reexperiencing or hyperarousal symptoms, except for patient ratings of reexperiencing. Relationship adjustment outcomes have not been reported (Sautter et al. 2009).
188.8.131.52 Emotionally Focused Couple Therapy for Trauma
Emotionally Focused Couple Therapy for Trauma (EFCT for Trauma) is a 12–20 session experiential couple therapy that focuses on identifying and understanding trauma-associated emotions. The therapy aims to determine how these emotions affect relationships, attachment, and communication. The intervention has three components: (1) identification of negative relational interactions, (2) dyadic skill-building through acceptance and communication, and (3) development and consolidation of positive patterns of interaction and coping strategies. Single-case and case replication studies report outcomes from the therapy (Greenman and Johnson 2012; Johnson 2002; MacIntosh and Johnson 2008). In the case study replication of ten couples, half of the participants reported improvements in relationship satisfaction at posttreatment and all participants with PTSD demonstrated clinically significant reductions in PTSD symptoms. Three couples in the study demonstrated an increase in emotional abuse and decreased relationship satisfaction over the course of the treatment. The authors caution that EFCT for Trauma may not be indicated for couples with ongoing emotional abuse (MacIntosh and Johnson 2008).
24.2.2 Partner-Assisted Interventions
184.108.40.206 Lifestyle Management Course
A 5-day, residential Lifestyle Management Course was developed for Australian military veterans and their partners to address quality of life and psychological symptoms (Devilly 2002). The course was delivered in a group format, and various topics were discussed throughout the week, including diet and nutrition, relaxation, communication, PTSD psychoeducation, self-care, stress management, medications, alcohol use, anger management, self-esteem, problem-solving, and goal-setting. Although there were reductions in PTSD symptoms following the program, by 6-month follow-up the effects were minimal. Reductions in veterans’ depression, anxiety, and stress were sustained at 6-month follow-up. The partners of the veterans noted larger improvements on all measures except for anger. No improvements in relationship satisfaction were found.
24.2.3 Generic Couple Therapy
220.127.116.11 Behavioral Couple/Family Therapy
Behavioral Couple/Family Therapy (BC/FT) generally involves improving interactions among family members or partners and enhancing communication. A randomized controlled trial tested BFT following individual exposure treatment for PTSD with veterans (Glynn et al. 1999). Individuals who received BFT subsequent to individual exposure therapy had greater improvements in interpersonal problem-solving compared with those who did not. No additional improvements were seen in PTSD symptoms following BFT. Several uncontrolled studies of group BCT with veterans with PTSD and their female partners have yielded improvements in relationship functioning but not PTSD symptoms (e.g., Cahoon 1984; Sweany 1987).
18.104.22.168 K’oach Program
The K’oach program is a month-long intensive treatment program for Israeli military veterans with PTSD (Rabin and Nardi 1991; Solomon et al. 1992). The program provides PTSD psychoeducation, communication, and problem-solving skills. The program incorporates spouses at several times over the course of treatment to learn cognitive, communication, and behavioral reinforcement skills. Minimal empirical research has been conducted on the efficacy of the K’oach program, although participants reported improved relationship satisfaction. No change was found in PTSD symptoms (Solomon et al. 1992).
24.2.4 Education and Family Facilitated Engagement
22.214.171.124 Support and Family Education Program
The Support and Family Education (SAFE) program is a 14-session educational program for the loved ones of veterans with mental illness (Sherman 2003). The program is delivered in a monthly workshop format. It is designed for a range of mental health difficulties (e.g., PTSD, schizophrenia, depression) and for any family member to attend. The program includes psychoeducation about mental health difficulties, as well as four sessions of skills training, problem-solving, and stress reduction. Although no assessment of the impact of the SAFE program on PTSD symptoms and/or relationship functioning for the individual with PTSD or their loved ones has been conducted, 3- and 5-year program evaluations report very high participant satisfaction (Sherman 2003, 2006). Findings suggest that program participation led to increased understanding of mental health difficulties, awareness of resources, and increased ability to engage in self-care activities. Fewer attended sessions were associated with higher distress in loved ones (Sherman 2003).
126.96.36.199 Reaching Out to Educate and Assist Caring, Healthy Families Program
The Reaching Out to Educate and Assist Caring, Healthy Families (REACH) program is a 16-session psychoeducation program for veterans with mental health difficulties and their family members (Sherman et al. 2009b). The program consists of three phases. The first phase is a 4-week session conducted with the veteran and his or her family. This phase focuses on goal-setting and rapport building. The second phase is a 6-week session of diagnosis-specific psychoeducation for a group of four to six veterans and their families. The third phase is 6-month group session to support ongoing education and maintain gains. A preprogram motivational interviewing strategy was also used to engage veterans with the REACH program (Sherman et al. 2009a). Participants with PTSD had a relatively high rate of retention across phases I and II of the program (of those who began phase I, 90 % completed that phase, and 97 % who began phase II completed that phase), although there was 25 % attrition between phases I and II (Sherman et al. 2011). Data was not reported for phase III. Participants reported high satisfaction with the program (Sherman et al. 2011). No data regarding PTSD symptom change or relationship satisfaction was reported.
188.8.131.52 Coaching into Care Program
A program has been developed whereby loved ones of veterans who are suspected to have PTSD and other trauma-related symptoms can call a telephone support service to receive guidance on how to facilitate engagement of their loved one in treatment. The program provides information about available treatment options, allowing loved ones to assist the veteran in accessing care in a non-coercive manner. Initial program evaluation has demonstrated some increase in veteran engagement in mental health services after use of the program (Sayers et al. 2011).
The mental health field is beginning to recognize the permeating effects of trauma and PTSD on interpersonal relationships and the role of these relationships in improving the lives and well-being of those with PTSD. There are a variety of ways in which partners might be incorporated into treatment, including disorder-specific couple therapy, partner-assisted interventions, general couple therapy, and education and engagement interventions. The class of disorder-specific couple therapy for PTSD has the strongest empirical support in terms of achieving multiple outcomes (i.e., reductions in PTSD, improvements in relational functioning, improvements in partners’ psychological functioning). Because PTSD has systemic-level implications for relationships with loved ones, targeting both the individual with PTSD and their partner in treatment seems to have greater effects across both symptom and relational domains. If the client and the partner are both willing to participate in a dyadic intervention for PTSD, disorder-specific couple therapy is recommended, regardless of level of relationship distress, because these interventions have been tested with couples across the spectrum of relationship satisfaction. Caution should be heeded, however, if the couple has ongoing emotional abuse for interventions focused explicitly on emotions.