Posted August 19, 2020

Steffany J. Fredman, Ph.D., Pennsylvania State University

Posttraumatic stress disorder (PTSD) is a common mental health consequence of military deployment, affecting an estimated 15% of Service members and 23% of Veterans who have deployed to Iraq and/or Afghanistan^[1],[2]. PTSD is recognized as associated with relationship distress, physical and psychological aggression, and partner psychological distress^[3],[4]. Studies of cognitive-behavioral therapy for PTSD have shown that family negativity is associated with poorer individual treatment outcomes^[5]. Partners may unknowingly engage in behaviors that inadvertently reinforce PTSD symptoms by accommodating patients’ symptoms through colluding in avoidance and safety behaviors intended to minimize patients’ PTSD-related distress or relationship conflict^[6]. Cognitive behavioral conjoint therapy (CBCT) for PTSD^[7], a 3-phase, 15-session treatment for PTSD delivered in a conjoint format, has demonstrated improvements in PTSD symptoms, comorbid symptoms, and relationship satisfaction in active duty, Veteran, and community couples^[8]. CBCT for PTSD is efficacious in improving PTSD symptoms and relationship adjustment among couples with PTSD. However, there is a need for more efficient delivery formats to maximize engagement and retention and to achieve faster outcomes in multiple domains. Dr. Steffany J. Fredman received a Fiscal Year 2013 Consortium to Alleviate PTSD Award through the Psychological Health and Traumatic Brain Injury Research Program to design and pilot an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD). 

Dr. Fredman tested the efficacy of her abbreviated, intensive, multi-couple group version of CBCT for PTSD in ameliorating clinician-rated PTSD symptom severity for active duty Service members and Veterans with PTSD. She evaluated the efficacy of the intervention for PTSD symptom severity, comorbid symptom severity (depression, anxiety, anger), both partners’ relationship satisfaction, and partner psychological well-being (e.g., depression, anxiety, anger). The study recruited 24 heterosexual couples (mean relationship length = 14.56 years) that included an active duty Service member or Veteran with PTSD who had deployed in support of combat operations following September 11, 2001 and experienced a trauma during deployment. Couples were included if they were married or had been cohabiting for a minimum of 3 months and included a Service member or Veteran who met the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnostic criteria for current PTSD according to the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and had a CAPS-5 score greater than 25. All couples completed treatments, which were delivered over a weekend. The assessments were conducted by clinical evaluators at 1- and 3-month time points after the weekend intervention. The weekend retreat component of AIM-CBCT for PTSD consisted of approximately 12 hours of CBCT for PTSD programming delivered consecutively over 2 days, with a primary focus on content from the first two phases of CBCT for PTSD. The first phase included psychoeducation about PTSD and relationship functioning, rationale for treatment, and the promotion of physical and emotional safety in the relationship via behavioral conflict management skills. The second phase included behaviorally focused interventions designed to enhance relationship functioning and assignment of couple-level approach tasks to address PTSD-related avoidance and partner accommodation of symptoms. Content was delivered in seven modules lasting approximately 60-90 minutes each. 

Dr. Fredman hypothesized that there would be significant improvements with respect to (a) clinicians’ ratings of patients’ PTSD symptom severity, (b) patients’ self-reported PTSD symptoms and comorbid symptom severity, (c) partners’ psychological distress, (d) both partners’ relationship satisfaction, and (e) participants’ satisfaction with the program. Patient and partner depressive symptom severity were assessed via the Patient Health Questionnaire-9; the Generalized Anxiety Disorder Screener was used to assess generalized anxiety symptomology; the State Anger subscale of the State-Trait Anger Expression Inventory-2 was used to assess participants’ feelings; Couples’ relationship satisfaction was assessed using the Couples Satisfaction Index, a well-validated, self-report measure that assesses satisfaction in intimate dyads; and participants’ satisfaction with the intervention was assessed using the Client Satisfaction Questionnaire-8. Results revealed significant reductions in clinician-rated PTSD symptoms, and in patients’ self-reported symptoms of PTSD, depression, anxiety, and anger, relative to baseline. By the 3-month follow-up, partners reported significant reductions in patients’ PTSD symptoms, as well as significant improvements in their own depressive symptoms, anxiety, and relationship satisfaction, relative to baseline. Patients and partners also reported high satisfaction with the program. Delivering CBCT for PTSD through an abbreviated, intensive multi-couple group format may be an efficient strategy for increasing patient participation and improving patient, partner, and relational well-being in military and Veteran couples with PTSD. Dr. Fredman plans to validate this study findings in a larger cohort.

 

References:

[1] Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Harnessing the healing power of relationships. New York, NY: Guilford Press.

[2] Fulton, J. J., Calhoun, P. S., Wagner, H. R., Schry, A. R., Hair, L. P., Feeling, N., … Beckham, J. C. (2015). The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans: A meta-analysis. Journal of Anxiety Disorders, 31, 98-107.

[3] Taft, C. T., Watkins, L. E., Stafford, J., Street, A. E., & Monson, C. M. (2011). Posttraumatic stress disorder and intimate relationship problems: A meta-analysis. Journal of Consulting and Clinical Psychology, 79(1), 22-33. https://doi.org/10.1037/a0022196

[4] Lambert, J. E., Engh, R., Hasbun, A., & Holzer, J. (2012). Impact of posttraumatic stress disorder on the relationship quality and psychological distress of intimate partners: A meta-analytic review. Journal of Family Psychology, 26(5), 729-737. https://doi.org/10.1037/a0029341

[5] Tarrier, N., Sommerfield, C., & Pilgrim, H. (1999). Relatives' expressed emotion (EE) and PTSD treatment outcome. Psychological Medicine, 29, 801–811.

[6] Fredman, S. J., Vorstenbosch, V., Wagner, A. C., Macdonald, A., & Monson, C. M. (2014). Partner accommodation in posttraumatic stress disorder: Initial testing of the Significant Others’ Response to Trauma Scale (SORTS). Journal of Anxiety Disorders, 28, 372-381.

[7] Monson, C. M., Fredman, S. J., Macdonald, A. M., Pukay-Martin, N. D., Resick, P. A., & Schnurr, P. P. (2012). Effect of cognitive-behavioral couple therapy for PTSD: A randomized controlled trial. Journal of the American Medical Association, 308, 700-709.

[8] Liebman, R. E., Whitfield, K., Sijercic, I., Ennis, N., & Monson, C. M. (2020). Harnessing the healing power of relationships in trauma recovery: A review of cognitive-behavioral conjoint therapy for PTSD. Current Treatment Options in Psychiatry. Advance online publication. https://doi.org/10.1007/s40501-020-00211-1

Publications:

Fredman, S. J., Macdonald, A., Monson, C. M., Dondanville, K. A., Blount, T. H., Hall-Clark, B. N., Fina, B. A., Mintz, J., Litz, B. T., Young-McCaughan, S., Hancock, A. K., Rhoades, G. K., Yarvis, J. S., Resick, P. A., Roache, J. D., Le, Y., Wachen, J. S., Niles, B. L., McGeary, C. A., Keane, T. M., & Peterson, A. L., for the Consortium to Alleviate PTSD. (2020). Intensive, multi-couple group therapy for PTSD: A nonrandomized pilot study with military and veteran dyads. Behavior Therapy, 51(5), 700-714. https://doi.org/10.1016/j.beth.2019.10.003

Barnes JB, Pressau C, Jordan AH, et al. 2019. Consortium to alleviate PTSD. common data elements in the assessment of military-related PTSD research applied in the Consortium to Alleviate PTSD. Mil Med 1:184(5-6):218-226. 

Link:

Public and Technical Abstracts: STRONG STAR Consortium to Alleviate PTSD

 

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