Individual PE vs. Couples' Cognitive-Behavioral Therapy for Combat-Related PTSD
Candice Monson, PhD
Compare the efficacy of traditional Prolonged Exposure therapy, an evidence-based therapy that involves only the individual service member, to Cognitive-Behavioral Couples Therapy, which involves the service member and spouse and incorporates behavioral communication skills with traditional aspects of Cognitive Processing Therapy to address both individual and couple-level distress.
The military family plays a much more complex role in a soldier's life than simply "keeping the home fires burning." In fact, family members play a significant role in how service members adjust in the aftermath of their combat experiences. Studies of veterans from previous wars have found that the presence of adequate social support following combat is one of the strongest predictors of successful adjustment, and the absence of such support is associated with the persistence of posttraumatic stress disorder (PTSD). Families often represent the chief source of support, so developing programs to assist military families in adjusting to deployment and providing support to the returning combatant is vital.
Unfortunately, the individuals most in need of family support may be least able to obtain it. Symptoms of PTSD, such as emotional numbing, irritability, and anhedonia, or the inability to experience pleasure in normally pleasurable acts, can push loved ones away and cause relationships to deteriorate. Studies reveal that both veterans and their partners report significant marital and family problems associated with veterans' PTSD symptoms, including lower relationship satisfaction, less cohesive relationships, less emotional expression and intimacy in their relationships, and more conflict in the relationships. Studies also have found elevated levels of anger, hostility, conflict, and violence in the families of veterans with PTSD.
The interdependence of individual and family adjustment can lead to a negatively spiraling process. As individual distress and PTSD symptoms worsen, family difficulties are likely to increase, and as family difficulties increase, so does stress upon the individual. But this process does not have to be only negative; it also can work in a positive direction. When families are able to provide a safe, stable environment for the returning service members, they can help to promote a more positive adjustment process, and when service members are able to reach out and reconnect with family members, it can strengthen the family structure.
Getting the family to help with treatment, and treatment to help the family
Several treatments have been proposed or developed to address the needs of families following trauma. Some focus on relieving family distress rather than focusing on a particular individual's PTSD symptoms. Alternatively, other programs focus on the role of the partner and family members in helping the trauma survivor to recover from the symptoms arising from the trauma. These approaches are not mutually exclusive, and one recently developed program, Cognitive-Behavioral Couples Therapy (CBCT) for PTSD, includes techniques designed both to treat PTSD and to reduce relationship distress. This program has shown promising results in small, uncontrolled studies of combat veterans with chronic PTSD.
Now, under the direction of Candice Monson, PhD, of Canada's Ryerson University, the STRONG STAR Consortium has designed a study to examine the efficacy of this treatment in a sample of active-duty military personnel who have recently returned from combat deployments. This randomized clinical trial compares traditional Prolonged Exposure therapy, which involves only the individual service member, to CBCT, which includes the service member's partner. It also includes behavioral communication skills training in addition to psychoeducation and cognitive interventions based on Cognitive Processing Therapy. Because the CBCT protocol addresses both individual and couple-level distress, Dr. Monson expects to see greater improvement in couple functioning with this treatment as she explores the role that military spouses can play in PTSD treatment and recovery.