Effect of cognitive-behavioral couple therapy for PTSD: a randomized controlled trial

Interventions That Support or Involve Caregivers or Families of Patients with Traumatic Injury: a Systematic Review

BACKGROUND

Almost 40 million family caregivers care for a loved one with severe physical or cognitive impairments. The purpose of this review is to summarize evidence about the benefits of interventions to support or involve family members/caregivers of patients with trauma-related injury on caregiver, patient, and household outcomes.

METHODS

English-language peer-reviewed publications in MEDLINE, CINAHL, and PsycINFO from 1995 through December 2016 were identified. Eligible studies included RCT or quasi-experimental studies evaluating interventions designed to support or involve caregivers or family members of patients with TBI, PTSD, or polytrauma. Abstractions were completed by one reviewer and checked by a second; two reviewers independently assessed risk of bias using the Cochrane Effective Practice and Organization of Care Review Criteria.

RESULTS

Thirteen studies (n = 9 TBI; n = 4 PTSD, n = 0 polytrauma) evaluated psychological or rehabilitation interventions involving caregivers. Interventions did not improve TBI patients' functional status (standardized mean difference [SMD], 0.29 [95% confidence interval [CI], - 0.51 to 1.08]) or psychological symptoms (SMD - 0.25, CI - 0.62 to 0.12). Qualitative analysis shows potential intervention benefit for TBI symptoms. Interventions did not improve TBI caregiver psychological symptoms (SMD - 0.26, CI - 0.57 to 0.05); however, qualitative analysis suggests mixed effects for caregiver burden and quality of life. Positive intervention effects on patients' PTSD symptoms, mental health service use, and PTSD caregivers' psychological symptoms were identified with certain interventions. Strength of evidence ranged from moderate to very low.

DISCUSSION

Studies showed mixed patterns of intervention effects on caregiver and patient outcomes; evidence about intervention impact is inconclusive. This review is the first to identify caregiving interventions for patients with TBI and polytrauma and extends past reviews about patients with PTSD. Limitations include a small evidence base, low study quality, disparate methods, varied outcome measures, and high heterogeneity. PROSPERO Registration CRD42017053516.

Sexual vs. Non-sexual trauma, sexual satisfaction and function, and mental health in female veterans

Trauma in general, and sexual assault in particular, is associated with serious mental health and functional problems. The quality of sexual satisfaction/function may be particularly impacted by sexual assault, and such sexual problems may account for some of the broader mental health and functioning impairments in sexual assault survivors. Accordingly, we examined self-reports of sexual health and mental health in a sample of 255 female veterans in committed, monogamous relationships who provided data regarding sexual assault (n = 153) or nonsexual trauma (n = 102). Trauma type was not associated with differences in sexual function, but sexual trauma was associated with significantly lower sexual satisfaction, greater posttraumatic stress disorder (PTSD) and depressive symptoms, and higher suicidal ideation. Furthermore, the indirect effect of trauma type on all mental health outcomes was significant via sexual satisfaction but not via sexual function. Finally, trauma type moderated the association of sexual function with suicidality, such that the association was significantly positive in those with a history of sexual assault but nonsignificant in those with nonsexual trauma. These results suggest that (1) female veterans' experience of sexual assault is related to sexual satisfaction, which in turn is related to mental health outcomes, and (2) a history of sexual assault may increase the importance of sexual functioning with regard to suicidality.

Couple Therapy with Veterans: Early Improvements and Predictors of Early Dropout

Family services within Veterans Affairs Medical Centers fulfill an important role in addressing relationship distress among Veterans, which is highly prevalent and comorbid with psychopathology. However, even for evidence-based couple therapies, effectiveness is weaker compared to controlled studies, maybe because many Veteran couples drop out early and do not reach the "active" treatment stage after the 3-4 session assessment. In order to improve outcomes, it is critical to identify couples at high risk for early dropout, and understand whether couples may benefit from the assessment as an intervention. The current study examined (a) demographics, treatment delivery mode, relationship satisfaction, and psychological symptoms as predictors of dropout during and immediately following the assessment phase, and (b) changes in relationship satisfaction during assessment. 174 couples completed questionnaires during routine intake procedures. The main analyses focused on 140 male Veterans and their female civilian partners; 36.43% dropped out during the assessment phase and 24.74% of the remaining couples immediately following the first treatment session. More severe depressive symptoms in non-Veteran partners were associated with dropout during assessment. Relationship satisfaction improved significantly during the assessment phase for couples who did not drop out, with larger gains for non-Veteran partners. No demographics or treatment delivery mode were associated with dropout. Although more research is needed on engaging couples at risk for early dropout and maximizing early benefits, the findings suggest that clinicians should attend to the civilian partner's and Veteran's depressive symptoms at intake and consider the assessment part of active treatment.

The Development and Implementation of a Multi-Couple Therapy Model with Torture Survivors in the Democratic Republic of the Congo

In this article, we present development and feasibility of implementation of a multi-couple group for use with torture-surviving couples. The model was developed in the Democratic Republic of the Congo in a community that experienced widespread torture during the wars from 1998 to 2004. The Torture-Surviving Couple Group model is a short-term intervention designed to use few human resources to address relational difficulties resulting from exposure to traumatic stressors. The model was guided by critical and feminist epistemologies and employed an ecological lens to incorporate neurobiology and attachment processes along with narrative therapy techniques. An existing multi-couple group model for addressing violence (Stith, Rosen, McCollum, & Thomsen, ), and a stage model for healing trauma (Herman, ) also informed the structural development of the Torture-Surviving Couple Group model. Couple groups were conducted using a 10-session program with 13 couples who met weekly. Session themes were incorporated into four phases emphasizing: (a) preparation; (b) safety and stabilization; (c) processing the relationship effects of trauma and grief; and (d) reintegration and rebuilding couple and family life. Couples reported and showed remarkable progress in their relationships after participating in the groups. Clinical and research implications and discussed along with the feasibility of developing and testing the model in a post-conflict low income setting.

Trauma Symptoms, Communication, and Relationship Satisfaction in Military Couples

Trauma symptoms are negatively correlated with couple relationship satisfaction, which is of particular importance in the relationships of military personnel who are often exposed to trauma whilst on overseas deployment. This study tested a model in which communication mediated an association between trauma symptoms and low relationship satisfaction. Thirty-one Australian military couples were observationally assessed during a communication task, and assessed on their relationship satisfaction and individual functioning. As expected, trauma symptoms in the male military spouse were associated with low satisfaction in both spouses. Females' low positive communication fully mediated the relationship between males' trauma symptoms and low female satisfaction, but not male relationship satisfaction. Unexpectedly, males' negative communication behaviors were associated with high male relationship satisfaction, and partially mediated the association between trauma symptoms and male satisfaction. Discussion focused on how some communication usually thought of as negative might be associated with relationship satisfaction in military couples.

Proximal relationships between social support and PTSD symptom severity: A daily diary study of sexual assault survivors

BACKGROUND

In cross-sectional studies, social support and posttraumatic stress disorder (PTSD) symptoms appear related, in that higher severity of PTSD is associated with lower social support and vice versa. Theoretical models of the causal direction of this relationship differ. Most longitudinal studies suggest that PTSD symptoms erode social support over time, although some suggest that higher social support is prospectively associated with decrease in PTSD symptom severity. It is unclear, though, how social support and PTSD affect each other in the short term. The purpose of this study was to test day-to-day relationships between PTSD and social support to elucidate how PTSD and social support influence each other.

METHODS

Using 1173 daily observations from 75 college women who met screening criteria for lifetime sexual assault and past-month PTSD, this study tested same-day and next-day relationships between PTSD and social support using mixed models.

RESULTS

Within-person analyses indicated that, when PTSD was higher than usual on a given day, social support was higher the next day. Between-person analyses suggested that people with generally higher social support tended to have lower PTSD symptoms on a given day, but average PTSD symptom severity was not associated with day-to-day fluctuations in social support.

CONCLUSIONS

Rather than eroding in response to daily symptoms, social support might be sought out following increases in PTSD, and when received consistently, might reduce symptoms of PTSD in the short term. Interventions that increase college women's access to social support after sexual assault may thus be helpful in addressing PTSD.

Long-Term Effectiveness of Treatment-as-Usual Couple Therapy for Military Veterans

Despite the fact that veterans face increased psychological and relationship distress as a result of their service-related experiences, no study to date has explored the long-term effectiveness of couple therapy for veterans. In the present investigation, 238 individuals (113 couples and 12 additional individuals) completed assessments 18 months after termination of treatment-as-usual couple therapy at two Veteran Administration Medical Centers. From pretreatment to 18-month follow-up, couples experienced significant increases in relationship satisfaction (d = 0.59) and significant decreases in both psychological distress (d = -0.31) and presence of intimate partner violence (d = -0.47). Overall, pretreatment demographic, psychological, and relationship characteristics did not significantly moderate maintenance of gains across 18 months. However, African American individuals (d = -0.58) and individuals not reporting intimate partner violence at pretreatment (d = -0.46) experienced smaller improvements in relationship satisfaction through 18-month follow-up. Further, older participants showed smaller reductions in psychological symptoms 18 months after treatment (d = 0.16). Thus, for many veterans and their spouses, treatment-as-usual couple therapy is effective at intervening in psychological and relationship distress long-term. Moreover, the long-term effectiveness of couple therapy with veterans appears to generalize across many demographic, intrapersonal, and interpersonal factors.

Emotion Dysregulation and Social Support in PTSD and Depression: A Study of Trauma-Exposed Veterans

Emotion dysregulation has been associated with impaired interpersonal functioning and increased risk of posttraumatic psychopathology. Given that social support is a robust predictor of psychiatric morbidity following trauma exposure, we examined whether emotion dysregulation was associated with posttraumatic psychopathology through its negative effect on social support. Using self-report data from 90 military veterans (89.9% men) enrolled in an outpatient psychotherapy program for posttraumatic stress disorder (PTSD), we found that social support partially mediated the effect of emotion dysregulation on PTSD (P_M = .10) and depression symptoms (P_M = .14). When source of support was considered, friend (P_M = .08) and significant other support (P_M = .06) were greater mediators of the effect of emotion dysregulation on depression symptoms than family support (P_M = .01). There were no differential mediating effects for support providers on PTSD symptoms. Our findings indicate that social support is a statistically significant yet clinically limited mechanism through which emotion dysregulation is linked with psychiatric symptoms. Implications for these limitations and alternative potentially relevant interpersonal mechanisms are discussed.

The Role of Relationship Adjustment in an Integrated Individual Treatment for PTSD and Substance Use Disorders Among Veterans: An Exploratory Study

OBJECTIVE

Identifying factors that influence treatment outcomes of emerging integrated interventions for co-occurring posttraumatic stress disorder (PTSD) and substance use disorder is crucial to maximize veterans' health. Dyadic adjustment suffers among individuals with PTSD and substance use disorder and may be an important mechanism of change in treatment. This exploratory study examined the association between dyadic adjustment and treatment outcomes in individual integrated treatment for co-occurring PTSD and substance use disorder.

METHODS

Participants were treatment-seeking veterans (N = 15) participating in a larger randomized controlled trial examining the efficacy of a novel integrated treatment for co-occurring PTSD and substance use disorder. Multiple regression analyses controlling for baseline symptom severity and independent sample t-tests were used to examine the relation between dyadic adjustment and treatment outcome variables including PTSD, substance use disorder, and depression symptom severity.

RESULTS

Baseline dyadic adjustment was associated with session 12 PTSD symptom severity as measured by both the Clinician-Administered PTSD Scale (CAPS) and PTSD Checklist (PCL), such that participants with high dyadic adjustment had significantly lower session 12 CAPS and PCL scores compared to participants with low dyadic adjustment. Baseline dyadic adjustment was not associated with session 12 depression symptoms or frequency of substance use.

CONCLUSIONS

These findings suggest that while the primary determinant of treatment outcome in this sample is the application of an evidence-based intervention, dyadic adjustment may play a role in individual treatment outcome for some treatment-seeking veterans. Data from this study were derived from clinical trial NCT01365247.

Integrative Intensive Retreats for Veteran Couples and Families: A Pilot Study Assessing Change in Relationship Adjustment, Posttraumatic Growth, and Trauma Symptoms

We assessed a brief, systemic retreat-style intervention that was developed to address concerns about the utilization of services for veterans coping with traumatic stress. A total of 76 dyads (N = 152) were assessed before and after a 4-day retreat, which included psychoeducation, group and conjoint therapeutic sessions, and recreational relaxation components. Overall, participants reported a reduction in trauma symptoms, but only support persons experienced a significant increase in posttraumatic growth from pretest to posttest. Both veterans and their romantic partners reported an increase in relationship adjustment after the retreat. Opportunities to address the needs of this population by removing barriers to treatment and reducing feelings of isolation, as well as implications for similar treatments are discussed.

A Dyadic Perspective on PTSD Symptoms' Associations with Couple Functioning and Parenting Stress in First-Time Parents

Posttraumatic stress disorder (PTSD) symptoms are associated with disruptions in both couple functioning and parenting, and limited research suggests that, among military couples, perceptions of couple functioning and parenting stress are a function of both one's own and one's partner's mental health symptoms. However, this work has not been generalized to civilian couples, and little is known about the associations between PTSD symptoms and family adjustment in specific family developmental contexts. We examined PTSD symptoms' associations with perceived couple functioning and parenting stress within a dyadic context in civilian couples who had participated in a randomized controlled trial of a universal, couple-based transition to parenthood program and at least one member of the couple reported having experienced a Criterion A1 traumatic event. Results of actor-partner interdependence models revealed that parents' own and partners' PTSD symptoms were negatively associated with perceived couple functioning; contrary to expectation, the association of partners' PTSD symptoms with perceived couple functioning was strongest among men who received the intervention. A parent's own PTSD symptoms were positively associated with parenting stress for both men and women and were unexpectedly strongest for men who received the intervention. Partner PTSD symptoms were also positively associated with increased parenting stress for both men and women. Findings support a dyadic conceptualization of the associations between spouses' PTSD symptoms and family outcomes during the transition to parenthood and suggest that participating in a couple-based, psychoeducational program during this phase in the family life cycle may be particularly salient for men.

Neural circuits involved in the renewal of extinguished fear

The last 10 years have witnessed a substantial progress in understanding the neural mechanisms for the renewal of the extinguished fear memory. Based on the theory of fear extinction, exposure therapy has been developed as a typical cognitive behavioral therapy for posttraumatic stress disorder. Although the fear memory can be extinguished by repeated presentation of conditioned stimulus without unconditioned stimulus, the fear memory is not erased and tends to relapse outside of extinction context, which is referred to as renewal. Therefore, the renewal is regarded as a great obstruction interfering with the effect of exposure therapy. In recent years, there has been a great deal of studies in understanding the neurobiological underpinnings of fear renewal. These offer a foundation upon which novel therapeutic interventions for the renewal may be built. This review focuses on behavioral, anatomical and electrophysiological studies that interpret roles of the hippocampus, prelimbic cortex and amygdala as well as the connections between them for the renewal of the extinguished fear. Additionally, this review suggests the possible pathways for the renewal: (1) the prelimbic cortex may integrate contextual information from hippocampal inputs and project to the basolateral amygdala to mediate the renewal of extinguished fear memory; the ventral hippocampus may innervate the activities of the basolateral amygdala or the central amygdala directly for the renewal. © 2017 IUBMB Life, 69(7):470-478, 2017.

The Role of Social Support in Cognitive-Behavioral Conjoint Therapy for Posttraumatic Stress Disorder

The current study examined the effect of total, as well as different sources (i.e., family, friends, significant other) of, pretreatment/baseline social support on posttraumatic stress disorder (PTSD) severity and treatment response to cognitive-behavioral conjoint therapy (CBCT) for PTSD. Thirty-six patients were randomized to receive treatment immediately or to a waitlist condition. Those in the treatment condition were offered CBCT for PTSD, a couple-based therapy aimed at reducing PTSD symptoms and improving relationship functioning. PTSD symptoms were assessed at pre-/baseline, mid-/4 weeks of waiting, and posttreatment/12 weeks of waiting using the Clinician-Administered PTSD Scale, and patients self-reported on their levels of pretreatment/baseline social support using the Multidimensional Scale of Perceived Social Support. Total support, as well as social support from family and friends, was not associated with initial PTSD severity or treatment response. However, there was a significant positive association between social support from a significant other and initial PTSD severity (g = .92). Additionally, significant other social support moderated treatment outcomes, such that higher initial significant other support was associated with larger decreases in PTSD severity for those in the treatment condition (g = -1.14) but not the waitlist condition (g = -.04). Social support from a significant other may influence PTSD treatment outcomes within couple therapy for PTSD. The inclusion of intimate partners and other family members may be a fruitful avenue for improving PTSD treatment outcomes; however, future studies are needed to examine whether support can be increased with treatment and whether those improvements lead to greater PTSD symptom response.

Expressed Emotion and Attributions in Relatives of Patients With Obsessive-Compulsive Disorder and Panic Disorder

Relatives' criticism of, hostility toward, and emotional overinvolvement (EOI) with patients are predictive of treatment response and relapse. Although these constructs have been linked to relatives' attributions for patient problems, little research has yet evaluated attributions for specific types of problems. This study examined event-specific attributions (i.e., attributions specifically for either disorder-related [DR] or non-DR problems) in relatives of patients with anxiety disorders. Relatives made more illness attributions (attributing problems to a patient's disorder) than controllable attributions (attributing problems to factors controllable by patients) for DR events, with the reverse pattern for non-DR events. Criticism and hostility were associated primarily with controllability attributions for non-DR events. In contrast, the presence of EOI was associated with illness attributions for non-DR events. Family-based interventions for anxiety disorders might need to focus on relatives' controllability attributions for a broad range of patient behaviors and on reducing tendencies to attribute non-DR problems to patients' disorders.

Consequences of PTSD for the work and family quality of life of female and male U.S. Afghanistan and Iraq War veterans

PURPOSE

Although it is well established that combat-related PTSD can lead to reduced quality of life, less is known about the relative effect of PTSD on different aspects of former service members' post-military readjustment. Moreover, research on female veterans' reintegration experiences is limited. This study aimed to document the work and family quality of life of post-9/11 male and female veterans and evaluate the gender-specific impact of PTSD on veterans' work and family outcomes.

METHODS

A national sample of 524 post-9/11 veterans completed mailed surveys as part of a longitudinal study. Descriptive and regression-based analyses were gender-stratified and weighted to enhance representativeness to the larger population.

RESULTS

With a few notable exceptions, the majority of post-9/11 U.S. veterans reported high work and family quality of life. PTSD was not associated with either employment or relationship status; however, it did predict poorer work and family functioning and satisfaction for both men and women, with the most consistent negative effects on intimate relationships. Several gender differences were found, primarily with respect to work experiences.

CONCLUSIONS

Although most post-9/11 veterans appear to be doing well in both their work and family lives, results support the need for interventions that can mitigate the negative effect of PTSD and other associated mental health conditions on several aspects of work and family quality of life. Findings contribute to research suggesting both similarities and differences in the post-military readjustment of male and female post-9/11 veterans and underscore the need for additional consideration of the unique work-related challenges women experience following military service.

Longitudinal Associations Between PTSD Symptoms and Dyadic Conflict Communication Following a Severe Motor Vehicle Accident

There are well-documented associations between posttraumatic stress disorder (PTSD) symptoms and intimate relationship impairments, including dysfunctional communication at times of relationship conflict. To date, the extant research on the associations between PTSD symptom severity and conflict communication has been cross-sectional and focused on military and veteran couples. No published work has evaluated the extent to which PTSD symptom severity and communication at times of relationship conflict influence each other over time or in civilian samples. The current study examined the prospective bidirectional associations between PTSD symptom severity and dyadic conflict communication in a sample of 114 severe motor vehicle accident (MVA) survivors in a committed intimate relationship at the time of the accident. PTSD symptom severity and dyadic conflict communication were assessed at 4 and 16weeks post-MVA, and prospective associations were examined using path analysis. Total PTSD symptom severity at 4weeks prospectively predicted greater dysfunctional communication at 16weeks post-MVA but not vice versa. Examination at the level of PTSD symptom clusters revealed that effortful avoidance at 4weeks prospectively predicted greater dysfunctional communication at 16weeks, whereas dysfunctional communication 4weeks after the MVA predicted more severe emotional numbing at 16weeks. Findings highlight the role of PTSD symptoms in contributing to dysfunctional communication and the importance of considering PTSD symptom clusters separately when investigating the dynamic interplay between PTSD symptoms and relationship functioning over time, particularly during the early posttrauma period. Clinical implications for the prevention of chronic PTSD and associated relationship problems are discussed.

Battling on the Home Front: Posttraumatic Stress Disorder and Conflict Behavior Among Military Couples

This study evaluated interpersonal behavior differences among male military service members with and without PTSD and their female partners. Couples (N = 64) completed a 17-minute videotaped conflict discussion, and their interaction behavior was coded using the circumplex-based Structural Analysis of Social Behavior model (SASB; Benjamin, 1979, 1987, 2000). Within couples, the behavior of partners was very similar. Compared to military couples without PTSD, couples with PTSD displayed more interpersonal hostility and control. Couples with PTSD also exhibited more sulking, blaming, and controlling behavior, and less affirming and connecting behavior, than couples without PTSD. Results advance our understanding of the relational impacts of PTSD on military service members and their partners, and underscore the value of couple-based interventions for PTSD in the context of relationship distress.

Using reinforcement sensitivity to understand longitudinal links between PTSD and relationship adjustment

There is limited research testing longitudinal models of how posttraumatic stress disorder (PTSD) severity leads to impaired relationship adjustment. The present study evaluated 2 potential mechanisms among a longitudinal sample of National Guard soldiers deployed to the Iraq War: (1) sensitivity to cues associated with punishment within intimate relationships and (2) sensitivity to cues associated with incentives in intimate relationships. Participants were surveyed by mail 1 year after an extended 16-month combat deployment and again 2 years later. Using a cross-lagged panel analysis with 2 mediators (relationship-specific threat and incentive sensitivity), findings indicated Time 1 PTSD symptom severity significantly eroded relationship adjustment over time through greater sensitivity to cues of relationship-related punishment, but not through incentive sensitivity. Additionally, findings indicated sensitivity to cues of relationship-related threats maintains symptoms of PTSD while sensitivity to cues of relationship-related incentives maintains relationship adjustment. Finally, PTSD symptoms significantly predicted erosion of relationship adjustment over time; however, associations from relationship adjustment to changes in PTSD severity over time were nonsignificant. Findings are discussed within the context of reinforcement sensitivity theory and emotional processing theory of PTSD. (PsycINFO Database Record

The incorporation of emotion-regulation skills into couple- and family-based treatments for post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a disabling, potentially chronic disorder that is characterized by re-experience and hyperarousal symptoms as well as the avoidance of trauma-related stimuli. The distress experienced by many veterans of the Vietnam War and their partners prompted a strong interest in developing conjoint interventions that could both alleviate the core symptoms of PTSD and strengthen family bonds. We review the evolution of and evidence base for conjoint PTSD treatments from the Vietnam era through the post-911 era. Our review is particularly focused on the use of treatment strategies that are designed to address the emotions that are generated by the core symptoms of the disorder to reduce their adverse impact on veterans, their partners and the relationship. We present a rationale and evidence to support the direct incorporation of emotion-regulation skills training into conjoint interventions for PTSD. We begin by reviewing emerging evidence suggesting that high levels of emotion dysregulation are characteristic of and predict the severity of both PTSD symptoms and the level of interpersonal/marital difficulties reported by veterans with PTSD and their family members. In doing so, we present a compelling rationale for the inclusion of formal skills training in emotional regulation in couple-/family-based PTSD treatments. We further argue that increased exposure to trauma-related memories and emotions in treatments based on learning theory requires veterans and their partners to learn to manage the uncomfortable emotions that they previously avoided. Conjoint treatments that were developed in the last 30 years all acknowledge the importance of emotions in PTSD but vary widely in their relative emphasis on helping participants to acquire strategies to modulate them compared to other therapeutic tasks such as learning about the disorder or disclosing the trauma to a loved one. We conclude our review by describing two recent innovative treatments for PTSD that incorporate a special emphasis on emotion-regulation skills training in the dyadic context: structured approach therapy (SAT) and multi-family group for military couples (MFG-MC). Although the incorporation of emotion-regulation skills into conjoint PTSD therapies appears promising, replication and comparison to cognitive-behavioral approaches is needed to refine our understanding of which symptoms and veterans might be more responsive to one approach versus others.

The Role of Context in the Implementation of Trauma-Focused Treatments: Effectiveness Research and Implementation in Higher and Lower Income Settings

In recent years, the implementation of trauma-focused treatments has expanded across settings that vary widely in the availability of resources, infrastructure, and personnel. The present review aims to inform researchers, policy makers, trainers, and administrators about this diverse range of research. Taking a global health perspective, this review of effectiveness trials and implementation studies compares strategies used in high-income countries to those in low- and medium-income countries. A primary difference between studies in high-income and low- and medium-income countries is the relative emphasis placed on fidelity or adaptation. Adaptations used in low- and medium-income countries might offer useful ideas for increasing the portability, impact, and accessibility of evidence-based interventions in high-income countries.

Leveraging Spousal Support to Improve Health Promotion in Serious Mental Illness

Although the majority of Veterans are overweight or obese, and many have comorbid mental health disorders, little is known about the most effective way to intervene in this complex population. This case describes a telephone-based cognitive-behavioral treatment for depression and weight management with an obese Veteran with bipolar disorder. His wife joined sessions to leverage spousal support. The Veteran evidenced variable levels of physical activity and mood fluctuations during treatment; although he reported some degree of positive behavior change and improved social support, he did not lose weight. He continued to endorse moderate levels of depressive symptomatology at the end of the nine-session intervention. This case illustrates the complexity of treating those with chronic serious mental illness and multimorbidities. Further research is needed to inform interventions that concurrently improve mental health symptomatology and weight-related outcomes in chronic, complex cases.

Posttraumatic Stress Disorder Symptoms, Intimate Partner Violence, and Relationship Functioning: A Meta-Analytic Review

This meta-analysis was the first study of which we are aware to investigate the association between Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) PTSD symptom clusters and parent, child, family, and marital/partner functioning problems (e.g., intimate partner violence [IPV] and intimacy). Of the 23 studies that met inclusion criteria, the sample was predominantly male (83.8%), Caucasian (65.0%), and from the military (98.9%). The average age was 43.65 years old (SD = 6.27); the average sample size was 397.4 (SD = 416.9; total N = 9,935). PTSD symptom clusters were assessed primarily by self-report (87.0%), with 8.7% using a rating by a clinician. We used fixed analysis following Fisher's r to z transformation and an unbiased weighing and summing of effect sizes within samples and across studies. We found a small association between hyperarousal and IPV (z = .20). We also found two moderate associations for the emotional numbing and avoidance symptom clusters: (a) with parent, child, and family functioning (z = .32, z = .28, respectively); and (b) with intimacy problems (z = .35, z = .42, respectively). We found two large associations for emotional numbing: marital and parent problems (z = .47) and parent, child, and family functioning problems (z = .32, respectively). Our findings suggested that treatments aim to lessen the effect on those who have close relationships with the individual with PTSD.

Couples Therapy for Intimate Partner Violence: A Systematic Review and Meta-Analysis

Intimate partner violence is a serious public health problem accompanied by substantial morbidity and mortality. Despite its documented impact on health, there is no widely recognized treatment of choice. Some studies indicate that couples suffering from situational violence may benefit from couples therapy, but professionals are cautious to risk the possibility of violent retaliation between partners. After a comprehensive literature search of 1,733 citations, this systematic review and meta-analysis compiles the results of six studies to investigate the effectiveness of couples therapy as a treatment for violence. Preliminary data suggest that couples therapy is a viable treatment in select situations.

Cognitive-behavioral couple therapy

This article describes how cognitive-behavioral couple therapy (CBCT) provides a good fit for intervening with a range of stressors that couples experience from within and outside their relationship. It takes an ecological perspective in which a couple is influenced by multiple systemic levels. We provide an overview of assessment and intervention strategies used to modify negative behavioral interaction patterns, inappropriate or distorted cognitions, and problems with the experience and regulation of emotions. Next, we describe how CBCT can assist couples in coping with stressors involving (a) a partner's psychological disorder (e.g. depression), (b) physical health problems (e.g. cancer), (c) external stressors (e.g. financial strain), and (d) severe relational problems (e.g. partner aggression).

Cognitive-Behavioral Couple Therapies: Review of the Evidence for the Treatment of Relationship Distress, Psychopathology, and Chronic Health Conditions

Cognitive-behavioral couple therapy (CBCT) is an approach to assisting couples that has strong empirical support for alleviating relationship distress. This paper provides a review of the empirical status of CBCT along with behavioral couple therapy (BCT), as well as the evidence for recent applications of CBCT principles to couple-based interventions for individual psychopathology and medical conditions. Several meta-analyses and major reviews have confirmed the efficacy of BCT and CBCT across trials in the United States, Europe, and Australia, and there is little evidence to support differential effectiveness of various forms of couple therapy derived from behavioral principles. A much smaller number of effectiveness studies have shown that successful implementation in community settings is possible, although effect sizes tend to be somewhat lower than those evidenced in randomized controlled trials. Adapted for individual problems, cognitive-behavioral couple-based interventions appear to be at least as effective as individual cognitive behavioral therapy (CBT) across a variety of psychological disorders, and often more effective, especially when partners are substantially involved in treatment. In addition, couple-based interventions tend to have the unique added benefit of improving relationship functioning. Findings on couple-based interventions for medical conditions are more varied and more complex to interpret given the greater range of target outcomes (psychological, relational, and medical variables).

Mental Health Difficulties and Help-Seeking Beliefs within a Sample of Female Partners of UK Veterans Diagnosed with Post-Traumatic Stress Disorder

In the UK there is a paucity of research about the needs of partners who are supporting ex-service personnel with mental health difficulties. In this study, we surveyed the mental health needs and barriers to help-seeking within a sample of partners of UK veterans who had been diagnosed with PTSD. Our sample included 100 participants. Forty-five percent met criteria for alcohol problems, 39% for depression, 37% for generalised anxiety disorder and 17% for symptoms of probable PTSD. Participants who met case criteria for depression, anxiety and problems with alcohol were more likely to report a greater number of help-seeking barriers. Participants who were experiencing mental health difficulties were more likely to endorse barriers connected to stigmatising beliefs than those associated with practical issues around accessing mental health services. The evidence presented suggests there may be a considerable burden of mental illness within this population. It would seem prudent to conduct further work to understand how best to address this clinical need.

Structured Approach Therapy for Combat-Related PTSD in Returning U.S. Veterans: Complementary Mediation by Changes in Emotion Functioning

To address the impact of combat-related posttraumatic stress disorder (PTSD) on U.S. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans, the investigators developed a 12-session manualized PTSD treatment for couples called structured approach therapy (SAT). A randomized controlled trial had shown that 29 OEF/OIF veterans with combat-related PTSD who had participated in SAT showed significantly greater reductions in PTSD compared to 28 veterans receiving a 12-session PTSD family education intervention (Sautter, Glynn, Cretu, Senturk, & Vaught, 2015). We conducted supplemental follow-up and mediation analyses, which tested the hypothesis that changes in emotion functioning play a significant role in the decreases in PTSD symptoms primarily observed in veterans who had received SAT. Veterans assigned to the SAT condition showed significantly greater decreases than those assigned to PTSD family education in emotion regulation problems (p < .001, Cohen's f(2) = .18) and fear of intense emotions (p < .001, Cohen's f(2) = .152). Decreases in both emotion regulation problems (mediated effect:ab̂= .36), and fear of intense emotions (mediated effect:ab̂ = .24) were found to be complementary mediators of reductions in PTSD symptoms greater with SAT. These findings suggest that SAT may aid veterans in improving their ability to regulate trauma-related emotions.

The Role of Posttraumatic Growth in a Randomized Controlled Trial of Cognitive-Behavioral Conjoint Therapy for PTSD

Posttraumatic growth (PTG) is defined as a positive psychological change that can emerge following a traumatic life event. Although documented in noninterventional studies of traumatized individuals, there are scant data on the potential for therapy to induce or improve PTG. Thus, the primary goal of this study was to examine changes in PTG in a controlled trial of cognitive-behavioral conjoint therapy for posttraumatic stress disorder versus waitlist (CBCT for PTSD; Monson & Fredman, 2012). We also examined whether pretreatment relationship satisfaction and PTSD symptomatology moderated change in PTG. There were 40 couples (75% with a female partner with PTSD) who were randomized to either immediate CBCT for PTSD or a 3-month waitlist (WL). Compared to WL, individuals who received treatment immediately demonstrated a significant increase in PTG. There was a moderate effect size between-group difference (Hedge's g = 0.45). There was a nonsignificant relationship with a moderate effect size (Hedge's g = 0.65) for the positive effect of pretreatment relationship satisfaction on the trajectory of PTG, but no effect of pretreatment PTSD symptoms. Results suggested that CBCT for PTSD facilitated PTG, even with a limited focus on PTG in this conjoint intervention. Future research should target PTG as a treatment goal and further examine the role of close others in facilitating development of PTG.

PTSD and Romantic Relationship Satisfaction: Cluster- and Symptom-Level Analyses

Previous studies have demonstrated bidirectional associations between posttraumatric stress disorder (PTSD) and romantic relationship dissatisfaction. Most of these studies were focused at the level of the disorder, examining the association between relationship dissatisfaction and having a diagnosis of PTSD or the total of PTSD symptoms endorsed. This disorder-level approach is problematic for trauma theorists who posit symptom-level mechanisms for these effects. In the present study, we examined the prospective, bidirectional associations between PTSD symptom clusters (e.g., reexperiencing) and relationship satisfaction using the data from 101 previously studied individuals who had had a recent motor vehicle accident. We also conducted exploratory analyses examining the prospective, bidirectional associations between individual PTSD symptoms and relationship satisfaction. Participants had completed the PTSD Checklist-Civilian Version and the Relationship Assessment Scale at 4, 10, and 16 weeks after the MVA. We performed time-lagged mixed-effects regressions to examine the effect of lagged relationship satisfaction on PTSD clusters and symptoms, and vice versa. No cluster effects were significant after controlling for a false discovery rate. Relationship satisfaction predicted prospective decreases in reliving the trauma (d = 0.42), emotional numbness (d = 0.46), and irritability (d = 0.49). These findings were consistent with the position that relationship satisfaction affects PTSD through symptom-level mechanisms.

Cognitive-behavioral conjoint therapy for PTSD improves various PTSD symptoms and trauma-related cognitions: Results from a randomized controlled trial

Numerous studies document an association between posttraumatic stress disorder (PTSD) and impairments in intimate relationship functioning, and there is evidence that PTSD symptoms and associated impairments are improved by cognitive-behavioral conjoint therapy for PTSD (CBCT for PTSD; Monson & Fredman, 2012). The present study investigated changes across treatment in clinician-rated PTSD symptom clusters and patient-rated trauma-related cognitions in a randomized controlled trial comparing CBCT for PTSD with waitlist in a sample of 40 individuals with PTSD and their partners (N = 40; Monson et al., 2012). Compared with waitlist, patients who received CBCT for PTSD immediately demonstrated greater improvements in all PTSD symptom clusters, trauma-related beliefs, and guilt cognitions (Hedge's gs -.33 to -1.51). Results suggest that CBCT for PTSD improves all PTSD symptom clusters and trauma-related cognitions among individuals with PTSD and further supports the value of utilizing a couple-based approach to the treatment of PTSD.

A Preliminary Examination of the Effects of Pretreatment Relationship Satisfaction on Treatment Outcomes in Cognitive-Behavioral Conjoint Therapy for PTSD

OBJECTIVE

The primary goal of the present study was to investigate whether pre-treatment relationship satisfaction predicted treatment drop-out and posttraumatic stress disorder (PTSD) symptom outcomes within a trial of cognitive-behavioral conjoint therapy (CBCT) for PTSD (Monson & Fredman, 2012). Additionally, we examined the influence of pre-treatment relationship distress on relationship outcomes.

METHOD

Thirty-seven patients and their intimate partners who participated in a course of CBCT for PTSD were assessed for PTSD symptoms with the Clinician-Administered PTSD Scale and PTSD Checklist, and for intimate relationship functioning with the Dyadic Adjustment Scale. CBCT for PTSD is a conjoint therapy designed to improve PTSD symptoms and enhance relationship functioning. Patients had to meet diagnostic criteria for PTSD to be included in the study; however, couples were not required to be in distressed relationships to receive treatment.

RESULTS

Neither patients' nor partners' pre-treatment relationship satisfaction, nor their interaction, predicted treatment drop-out (ORs = .97-1.01) or completing patients' post-treatment PTSD symptom severity (sr² ≤ .03). However, participants who were in distressed relationships prior to treatment made greater gains in relationship satisfaction compared with those who began treatment in more satisfied relationships (g = 1.02).

CONCLUSIONS

Among patients receiving CBCT for PTSD, treatment drop-out and improvements in PTSD symptoms may be independent of pre-treatment relationship functioning, whereas improvements in relational functioning may be greater among those distressed prior to treatment.

Partner accommodation moderates treatment outcomes for couple therapy for posttraumatic stress disorder

OBJECTIVE

Partner accommodation of posttraumatic stress disorder (PTSD) symptoms (i.e., altering one's own behaviors to minimize patient distress and/or relationship conflict due to patients' PTSD symptoms) has been shown to be positively associated with patient and partner psychopathology and negatively associated with patient and partner relationship satisfaction cross-sectionally. However, the prognostic value of partner accommodation in treatment outcomes is unknown. The goals of the present study were to determine if partner accommodation decreases as a function of couple therapy for PTSD and if pretreatment partner accommodation moderates the efficacy of couple therapy for PTSD.

METHOD

Thirty-nine patients with PTSD and their intimate partners (n = 39) were enrolled in a randomized controlled trial of cognitive-behavioral conjoint therapy (CBCT) for PTSD (Monson & Fredman, 2012) and received CBCT for PTSD immediately or after 3 months of waiting. Blinded assessors determined clinician-rated PTSD symptoms and patient-rated PTSD and depressive symptoms and relationship satisfaction at baseline, midtreatment/4 weeks of waiting, and posttreatment/12 weeks of waiting.

RESULTS

Contrary to expectation, partner accommodation levels did not change over time for either treatment condition. However, baseline partner accommodation significantly moderated treatment outcomes. Higher levels of partner accommodation were associated with greater improvements in PTSD, depressive symptoms, and relationship satisfaction among patients receiving CBCT for PTSD compared with waiting list. At lower levels of partner accommodation, patients in both groups improved or remained at low levels of these outcomes.

CONCLUSIONS

Individuals with PTSD who have more accommodating partners may be particularly well-suited for couple therapy for PTSD.

Multi-family Group Treatment for Veterans with Mood Disorders: A Pilot Study

Mood disorders affect large numbers of individuals and their families; the ripple effects on relationship functioning can be great. Researchers have advocated for a relational perspective to mood disorder treatment, and several promising treatments have been developed. However, few rigorous evaluations have been conducted within the Veterans Affairs (VA) system. Multifamily group therapy, an evidence-based practice for people living with schizophrenia, has recently been adapted for other psychological disorders with promising results. This report describes the first published evaluation of this treatment modality in the VA system for veterans living with mood disorders. 101 male veterans (74 with major depression and 27 with bipolar disorder) and their family members participated in REACH (Reaching out to Educate and Assist Caring, Healthy Families), a 9-month, manualized, multi-family group treatment, intervention adapted from McFarlane's original multi-family group model. Participants completed self-report questionnaires at four time points across the course of the treatment, and service utilization data for veterans were obtained from VA databases. Both veterans and family members showed improvements in their knowledge about mood disorders, understanding of positive strategies for dealing with situations commonly confronted in mood disorders, and family coping strategies. Veterans also evidenced improvement in family communication and problem-solving behaviors, empowerment, perceived social support, psychiatric symptoms, and overall quality of life. The REACH intervention holds promise as a feasible, acceptable, and effective treatment for veterans living with mood disorders and their families. Further study is warranted.

Cognitive-Behavioural Therapy and Psychodynamic Psychotherapy in the Treatment of Combat-Related Post-Traumatic Stress Disorder: A Comparative Effectiveness Study

This study compared the effectiveness of two psychotherapy approaches for treating combat veterans with chronic post-traumatic stress disorder (PTSD): cognitive-behavioural therapy (CBT) and psychodynamic psychotherapy (PDT). These treatments are routinely used by the Unit for Treatment of Combat-Related PTSD of the Israel Defense Forces (IDF). IDF veterans with chronic PTSD were assigned to either CBT (n = 148) or PDT (n = 95) based on the nature of their complaint and symptoms. Psychiatric status was assessed at baseline, post-treatment and 8-12 months follow-up using the Clinician-Administered PTSD Scale, the PTSD Questionnaire, the Montgomery and Asberg Depression Rating Scale and the Psychotherapy Outcome Assessment and Monitoring System-Trauma Version assessment questionnaire. Both treatment types resulted in significant reduction in symptoms and with improved functioning from pre-treatment to post-treatment, which were maintained at follow-up. No differences between the two treatments were found in any the effectiveness measures. At post-treatment, 35% of the CBT patients and 45% of the PDT patients remitted, with no difference between the groups. At follow-up, remission rates were 33% and 36% for the CBT and PDT groups, respectively. The study recommends further randomized controlled trials to determine treatment efficacy. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Both cognitive-behavioural therapy and psychodynamic psychotherapy have to be treatments offered in clinics for treating PTSD. Therapists who treat PTSD should be familiar with cognitive-behavioural and dynamic methods. The type of treatment chosen should be based on thorough psychosocial assessment.

Couple Treatment for Alcohol Use Disorder and Posttraumatic Stress Disorder: Pilot Results From U.S. Military Veterans and Their Partners

We studied 13 U.S. male military veterans and their female partners who consented to participate in an uncontrolled trial of couple treatment for alcohol use disorder and posttraumatic stress disorder (CTAP). CTAP is a 15-session, manualized therapy, integrating behavioral couples therapy for alcohol use disorder (AUD) with cognitive-behavioral conjoint therapy for posttraumatic stress disorder (PTSD). Due to ineligibility (n = 1) and attrition (n = 3), 9 couples completed the study, and 7 completed 12 or more sessions. There were 8 veterans who showed clinically reliable pre- to posttreatment reduction of PTSD outcomes. There were also significant group-level reductions in clinician-, veteran-, and partner-rated PTSD symptoms (d = 0.94 to 1.71). Most veterans showed clinically reliable reductions in percentage days of heavy drinking. Group-level reduction in veterans' percentage days of heavy drinking was significant (d = 1.01). There were 4 veterans and 3 partners with clinically reliable reductions in depression, and group-level change was significant for veterans (d = 0.93) and partners (d = 1.06). On relationship satisfaction, 3 veterans and 4 partners had reliable improvements, and 2 veterans and 1 partner had reliable deterioration. Group-level findings were nonsignificant for veteran relationship satisfaction (d = 0.26) and for partners (d = 0.52). These findings indicate that CTAP may be a promising intervention for individuals with comorbid PTSD and AUD who have relationship partners.

Veterans' PTSD symptoms and their partners' desired changes in key relationship domains

There is a growing literature investigating the connection between veterans' posttraumatic stress disorder (PTSD) symptoms and intimate relationship problems. Little to no work, however, has examined the connection between veterans' PTSD symptoms and their partners' perceptions of specific relationship areas in need of change. We examined associations between overall PTSD symptoms and symptom cluster scores with partners' desired changes in the areas of intimacy, shared activities, and responsibilities. The sample consisted of 249 male veterans of different service eras and their female partners. Results indicated that veterans' PTSD symptoms were associated with greater desired changes from their partners in the veterans' intimacy behaviors and participation in shared activities. When examining the contribution of each symptom cluster individually, only the veterans' emotional numbing symptoms emerged as a significant unique predictor and were associated with partners' desired changes in intimacy. The findings suggest that intimacy and shared activities may be relevant areas to address in PTSD treatment for veterans and their partners and highlight the particular significance of emotional numbing symptoms to intimacy in veterans' relationships.

Intimate partner relationship distress in the DSM-5

Over the past 40 years, a large body of literature has documented intimate partner relationship distress as a primary reason for seeking mental health services as well as an integral factor in the prognosis and treatment of a range of mental and physical health conditions. In recognition of its relevance to clinical care, the description of intimate partner relationship distress has been expanded in the DSM-5. Nonetheless, this is irrelevant if the DSM-5 code for intimate partner relationship distress is not reliably used in clinical practice and research settings. Thus, with the goal of dissemination in mind, the purpose of this paper was to provide clinicians and researchers with specific guidelines on how to reliably assess intimate partner relationship distress and how this information can be used to inform treatment planning. In addition to the implications for direct clinical care, we discuss the importance of reliable assessment and documentation of intimate partner relationship distress for future progress in epidemiology, etiology, and public health research.

Social relationship satisfaction and PTSD: which is the chicken and which is the egg?

BACKGROUND

Impaired social relationships are linked with higher levels of posttraumatic stress disorder (PTSD), but the association's underlying dynamics are unknown. PTSD may impair social relationships, and, vice versa, poorer relationship quality may interfere with the recovery from PTSD.

OBJECTIVE

This work longitudinally evaluates the simultaneous progression of PTSD symptoms and social relationship satisfaction (SRS) in a large cohort of recent trauma survivors. It also explores the effect of cognitive behavior therapy (CBT) on the association between the two.

METHOD

Consecutive emergency department trauma admissions with qualifying PTSD symptoms (n=501) were assessed 3 weeks and 5 months after trauma admission. The World Health Organization Quality of Life evaluated SRS and the Clinician Administered PTSD Scale evaluated PTSD symptom severity. Ninety-eight survivors received CBT between measurement sessions. We used Structural Equation Modeling to evaluate cross-lagged effects between the SRS and PTSD symptoms.

RESULTS

The cross-lagged effect of SRS on PTSD was statistically significant (β=-0.12, p=0.01) among survivors who did not receive treatment whilst the effect of PTDS on SRS was nil (β=-0.02, p=0.67). Both relationships were non-significant among survivors who received CBT.

DISCUSSION

SRS and PTSD are highly associated, and this study shows that changes in SRS in the early aftermath of traumatic events contribute to changes in PTSD, rather than vice versa. SRS impacts natural recovery, but not effective treatment. This study suggests that being satisfied with one's relationships might be considered as an important factor in natural recovery from trauma, as well as in intervention.

Assessing Treatment-Resistant Posttraumatic Stress Disorder: The Emory Treatment Resistance Interview for PTSD (E-TRIP)

Patients with posttraumatic stress disorder (PTSD) who fail to respond to established treatments are at risk for chronic disability and distress. Although treatment-resistant PTSD (TR-PTSD) is a common clinical problem, there is currently no standard method for evaluating previous treatment outcomes. Development of a tool that could quantify the degree of resistance to previously provided treatments would inform research in patients with PTSD. We conducted a systematic review of PTSD treatment trials to identify medication and psychotherapy interventions proven to be efficacious for PTSD. We then developed a semi-structured clinician interview called the Emory Treatment Resistance Interview for PTSD (E-TRIP). The E-TRIP includes clinician-administered questions to assess the adequacy and benefit derived from past treatment trials. For each adequately delivered treatment to which the patient failed to respond, a score is assigned depending on the strength of evidence supporting the treatment’s efficacy. The E-TRIP provides a comprehensive assessment of prior PTSD treatments that should prove valuable for researchers studying TR-PTSD and evaluating the efficacy of new treatments for patients with PTSD. The E-TRIP is not intended to guide treatment; rather, the tool quantifies the level of treatment resistance in patients with PTSD in order to standardize TR-PTSD in the research domain.