Rationale: Research has developed psychotherapies for post-traumatic stress disorder (PTSD) that can help a large number of service members (evidence-based treatments, or EBTs). These EBTs have been spread widely across Department of Veterans Affairs (VA) and Department of Defense (DoD) mental health clinics, yet as many as 2 in 5 Veterans drop out of these treatments and 50% finish with symptoms severe enough to still screen positive for PTSD. One of the best predictors of treatment response is attendance, and while daily homework assignments are central to treatment, many patients do not fully complete them. Supporting service members' efforts to fully engage in these treatments (i.e., adhere) may provide a powerful tool for maximizing their chances for recovery. One central and underutilized resource in this effort is families. Previous work demonstrates chronic family problems among those with PTSD. These family problems make it less likely that service members with severe symptoms of PTSD will even seek treatment, and when they do, family problems can lead patients with PTSD to actually experience less benefit from treatment. Despite clear need for family involvement in EBTs for PTSD, evidence-based strategies for how to involve families in these treatments have yet to be established. This study is the first step towards a solution. By studying Veterans and their families as they participate in EBTs for PTSD, we will develop a comprehensive and family-focused understanding of why some service members do not finish treatment and why those who do sometimes fail to fully recover.

Objectives: Our long-term objective is to develop evidence-based methods of involving families in EBTs for PTSD to improve treatment adherence. In order to build this intervention, we must first observe service members and their families as they participate in EBTs, as delivered in real-world settings, to identify when and how to intervene. Our immediate objectives are (1) to determine the influence of family on treatment adherence among service members referred to EBTs for PTSD; (2) to evaluate a family-centered model of why some service members adhere less to EBTs for PTSD; and (3) to obtain an in-depth understanding of the experiences of service members who adhere less to treatment in order to (a) identify experiences and unmeasured factors that may influence adherence and (b) identify service member, family, and provider preferences for family involvement.

Applicability of the Research and Contributions to the Field: This study will provide essential information to guide strategies to engage families during service members' recovery from PTSD, increase family support, and strengthen family relationships, promoting reintegration. The proposed work is the first step in providing service members with PTSD their best opportunity for recovery, through involving their families in their care. Findings from the present study will provide the evidence base for when, how, and why family involvement can improve treatment adherence and outcomes. From these findings, we will develop guidelines for providers, outlining how to involve the families in EBTs for PTSD, and an initial protocol for a family-centered intervention to improve adherence to EBTs for PTSD. The findings will have immediate clinical applications, and given the observational nature of the study, minimal risks are anticipated. This project fills important gaps in the literature and directly addresses the following two Psychological Health/Traumatic Brain Injury Research Program Task Areas: (1) Prevention, Diagnosis, and Treatment of Post-Traumatic Stress Disorders (PTSD) and (2) Military Family and Community Health and Resilience.