Running Head MUNCHAUSEN SYNDROMEMunchausen SyndromeKr.docx

Running Head: MUNCHAUSEN SYNDROME
Munchausen Syndrome
Krystina Joseph
Columbia College
Munchausen Syndrome Article Review
Introduction
The Munchausen Syndrome Article explains about the
Munchausen Syndrome, which is a rare fictitious disorder which
involves the frequent hospitalization together with an
intentional display of signs of sickness and pathological lying.
In this regards, the management needs the security history
taking with collaboration with the sound clinical processes
which entails organicity exclusion in addressing the
psychological problems. It is worth noting that a case which is
presented having unusual symptoms of same dimensions are as
well discussed. The case in this regards brings the finer nuances
in the assessment of the entity (Prakash., et al 2014).
Research Question
Based on the abstract of the article, it can be denoted that the
research question of the article is the need to understand more
on the Munchausen Syndrome as well as the symptoms and
therefore the need to ensure that such issues are solved by
having a sound clinical process to handle the problem. The

problem for the case as well was to find out what caused the 19-
year-old housewife to vomit pink substance.
Findings
The findings depict that the 19-year-old housewife was
suffering from a factitious disorder, also termed as the
Munchausen syndrome. The psychometry performed also
showed that there is an elevation of scales of anxiety together
with hysteria. Consequently, being managed in an empathetic as
well as non-confrontational manner, the psychotherapy was
intended to improve the positive coping abilities while at the
same time improving the interpersonal relationships which had
been imparted (Prakash., et al 2014).
Research Methods Used
The methods used involved observations and clinical
assessments. Observations were done by checking regularly the
presence of the bloodstained vomits as well as the asthenia and
any forms of skin allergy. This was carried out to ensure that
the patient had no issues. The observations, as well as little
conversation, showed that there were no cases of psychiatric
illnesses for the patient in the past. Further, the assessment
entails involves the systematic examinations which were
performed within the normal limit. The psychiatric evaluation
was performed together with ward observations which were
intended at revealing the comfortability of the patient while in
the hospital (Prakash., et al 2014).
The credibility of the Source of Information
To know the credibility of sources, the authors are scrutinized
where their qualifications and their areas of experience assessed
to understand whether the information provided is related to the
topic at hand. For this article, it can be denoted that all the
information provided is credible. This is because all the four
authors who contributed to the article have sufficient skills and
knowledge pertaining to health-related disorders, and thus, their
pieces of information are very accurate and thus helpful.
The relevance of the Article
The information contained in the article talks about the

factitious syndrome which the 19-year-old housewife is likely
to be suffering from. Fist, the article talks of the conditions as
well as the symptoms which helps in understanding more about
the disorder. Additionally, the article explains on the various
activities which are carried out in the hospital in diagnosing the
disorder very well so that the required medications are provided
(Prakash., et al 2014). This article is therefore relevant since it
explains on the factitious disorder sufficiently.
Refine of Original Question
From all the information provided. I will not change the original
question since the original question still explains that the article
is the need to understand more on the Munchausen Syndrome as
well as the symptoms and therefore the need to ensure that such
issues are solved by having a sound clinical process to handle
the problem. The problem for the case as well was to find out
what caused the 19-year-old housewife to vomit pink substance.
Conclusion
To sum up, it can be denoted that psychometry performed also
showed that there is an elevation of scales of anxiety together
with hysteria. Consequently, being managed in an empathetic as
well as non-confrontational manner, the psychotherapy was
intended to improve the positive coping abilities while at the
same time improving the interpersonal relationships which had
been imparted. Methods of research used as well entails
Observations were done by checking regularly the presence of
the bloodstained vomitus as well as the asthenia and any forms
of skin allergy. This was carried out to ensure that the patient
had no issues. The observations, as well as little conversation,
showed that there were no cases of psychiatric illnesses for the
patient in the past. Further, the assessment entails involves the
systematic examinations which were performed within the
normal limit.
Reference
Prakash, J., Das, R. C., Srivastava, K., Patra, P., Khan, S. A., &
Shashikumar, R. (2014). Munchausen syndrome: Playing sick or

sick player. Industrial psychiatry journal, 23(1), 68.
Term Paper Guidelines
Objective
You will write a research paper that uses your text and scholarly
articles to address the topic questions below. Your paper should
be written in APA format with 3-5 pages of text. It should also
include a reference page, title page and abstract (the page count
does not include those pages).
Topic: The Therapeutic Alliance
The general topic of your paper is the therapeutic alliance in
family therapy. Choose a more specific topic within that
concept. Some possible examples might be:
· If you and your family were in therapy, what type of working
relationship would you want to have with the clinician, why,
and how would your choice of relationship get you to your
goals?
Working with PTSD in families.
Guidelines
· Use your text and at least one professional/peer-reviewed
journal article.
· Papers should be written using APA format and style
standards. A link to a popular APA format and style guide is
included under the Research Paper module in the Content area.
· Do not use direct quotations in this paper. Paraphrase your
sources to demonstrate your understanding of the material and
cite these sources properly. Papers with direct quotations may
be dropped a letter grade. Listing a source on the reference page
is not sufficient to address proper citation of sources. In-text
citations are required. Note: To paraphrase, you must put your
source’s material in your own words. Do not use material word-
for-word from your sources without using quotation marks and

citing them, otherwise this will be considered a form of
plagiarism.
· Papers should be double-spaced with 12-point font. Do not
have any more than a double space at any point in the paper,
such as between paragraphs or on either side of a heading.
· Organization of the paper, as well as grammar, spelling and
punctuation also will be considered in grading.
The role of relationships and families in healing
from trauma
Gabriela López-Zeróna and Adrian Blowb
The effects of trauma and its treatment have a central role in
health dis-
cussions in that trauma exposure is associated with an array of
mental
health issues, including depression, anxiety, and substance
abuse. Treat-
ment approaches are varied, but most empirically based
protocols are
individually focused, targeting intrapersonal difficulties.
Although these
protocols are critical, they do not directly address the
relationship diffi-
culties that may arise for survivors. In addition, limited
empirical evi-
dence supports using systemic approaches in trauma treatment.
This
article addresses this issue by summarizing the most salient
individual
and relational evidence-based trauma protocols and by
providing a

description of common factors among these approaches, while
also chal-
lenging the field to generate more research that emphasizes
systemic
interventions as a core consideration in treatment. A case study
is
included to illustrate the global relevance and benefit of
systemic trauma
approaches.
Practitioner points
• Trauma should be treated as an event that affects everyone in
the
family and is nested in societal and cultural contexts.
• Close relationships can maintain or exacerbate problems, but
they can also be a powerful source of healing.
• Systemic protocols that not only address intrapersonal
difficulties,
but also focus on survivors’ relationships are critical for healing
in
the aftermath of trauma.
Keywords: trauma; evidence-based practices.
a Doctoral student in the Couple and Family Therapy Program,
Department of Human
Development and Family Studies, Michigan State University,
Room 408, Human Ecology
Building, 552 West Circle Drive, East Lansing, MI 48824, USA.
E-mail: [email protected]
b Associate Professor, Couple and Family Therapy Program,
Department of Human
Development and Family Studies, Michigan State University.

VC 2016 The Association for Family Therapy and Systemic
Practice
Journal of Family Therapy (2017) 39: 580–597
doi: 10.1111/1467-6427.12089
The concept of trauma has received a great deal of clinical and
research attention over the past few decades. Globally, exposure
to
trauma is a chronic problem, as many individuals are exposed to
at
least one traumatic event over the course of their lifetime.
Traumatic
exposures can occur in a number of contexts including war,
family or
intimate relationship violence, motor vehicle accidents, natural
disasters and criminal events, or through life-threatening
illnesses.
Millions of individuals worldwide are affected by the aftermath
of
exposure to a traumatic event (Breslau, 2009).
Even though there is a growing body of research on the
interperso-
nal effects of trauma, most of the treatment focuses on the
individual
who directly experiences the traumatic event (van der Kolk,
2003)
and there is scant research assessing the outcomes of trauma
treat-
ment of couples and families (Lebow and Rekart, 2013).
Although
sorting out the intrapersonal chaos caused by traumatic
experiences

is essential for healing, trauma is also a relational event that
affects the
individual survivor’s inner state and their web of close
relationships
(Kerig and Alexander, 2012, Matsakis, 2013). Positive family
support
is often central to the survivor’s recovery environment
(Herman,
1997). Close relationships may provide the necessary support
that
can allow traumatized individuals to reconnect with themselves
and
others and engage in a healing process (Figley and Figley,
2009).
As Johnson (2002) asserts, ‘the nature of the recovery
environment
play[s] a part in determining the long-term effects of traumatic
events’ (p. 26). In a review of studies of post-traumatic stress
disorder
(PTSD) Guay et al. (2006) conclude that the presence of social
support
is a key moderator in the development and treatment of post-
trau-
matic stress. However, it is not only the presence of social
support
that is important but also the quality of the recovery
environment
(Matsakis, 2013). Bracken et al. (1995) encourage clinicians to
contex-
tualize survivors’ experiences and consider the importance of
the
reconstruction of social, economic and cultural networks to
facilitate
healing and recovery. Negative interactions experienced in
close rela-

tionships increase the risk of developing or worsening PTSD.
In this article we summarize the most salient individual, group
and
relational evidence-based treatment approaches for trauma, and
dis-
cuss the importance of including family members in treatment.
We
also challenge the field of systemic interventions to provide
more
research and advocacy that will result in systemic interventions
becoming a core consideration in treatment of trauma survivors
and
their partners and family members. We begin our discussion by
Relationships and families in healing from trauma 581
Practice
providing an in-depth (although vivid) case study that illustrates
the
benefit of a systemic-oriented intervention.
Clinical case example
The following clinical example provides an illustration of
trauma and
differing outcomes, depending on whether a systemic or
relational
perspective is a part of treatment. This clinical case, based on
real-life
events, illustrates how the need for research and advocacy over
sys-

temic or relational trauma research is a top global public health
issue.
The case presents a graphic occurrence of trauma to which
people all
over the world are exposed, especially in countries ravaged by
pov-
erty, drug trafficking and war. As clinicians, it is important to
consider
that trauma is not an experience that happens only to the
individual,
but an event that influences every member of the family.
Alana Martin, aged 45, contacted a local mental health
practitioner seek-
ing counselling services after an extremely violent traumatic
event. The
Martin family lives in a small city in a Central American
country ridden
with violence and drug trafficking. James, aged 14, was
kidnapped from
his basketball practice one afternoon. Two men attacked and
murdered
his driver, a close family friend. James was taken away and held
in a
remote, secluded location. The kidnappers contacted his
parents, Mike
and Alana, a few hours later, asking for ransom money. Eddie,
aged 10,
James’ younger brother, was immediately removed from his
home and
sent to stay with an aunt in another city for his safety due to the
possibility
of subsequent kidnappings in these types of situations. Mike
and Alana
tried to reason with the kidnappers, asking them for enough
time to

attempt to gather the money for ransom. Their pleas were met
with
threats and increased pressure to deliver the money in its
entirety soon.
The couple pleaded for their son’s safety and promised to
deliver the
money as soon as possible. That night Mike and Alana had a
huge marital
argument after Mike blamed Alana for the kidnapping, claiming
she had
overlooked some common safety protocols. The next morning
they
received a small package with a piece of one of James’ toes.
Alana and
Mike both had severe panic attacks and were taken to the
emergency
room. Subsequently the Martins were able to secure the cash
they needed
and paid the ransom. James was returned to his family shortly
after.
Three months later, Alana is seeking counselling for her son
James, wor-
ried about his reintegration process after such a traumatic event.
James
has been reporting nightmares, flashbacks, trouble sleeping and
difficul-
ties in school. He has also refused to talk to his family about his
experi-
ence, saying that he would much rather just focus on the
positives in life.
Gabriela López-Zerón and Adrian Blow582
Practice

If Alana contacts a mental health practitioner who
conceptualizes
the experience of trauma and its subsequent treatment as an
individ-
ual process, the therapist might identify James as the client
present-
ing for treatment. The therapist might gravitate towards using
an
evidencebased approach centred on reducing the post-traumatic
stress symptoms and the integration of the traumatic event into
James’ narrative. Undoubtedly, based on the extensive body of
work
supporting exposure therapies for the treatment of trauma,
James
will experience relief and healing. His improvement might also
indi-
rectly positively impact on his family’s overall coping after
such a trau-
matic event. This kind of treatment would focus in the traumatic
event itself and the related thoughts, emotions, and internal
struc-
tures related to the trauma.
On the other hand, if the mental health practitioner adopts a
contextualized and relational treatment of trauma, the therapist
might
consider the entire Martin family as the client and involve
Alana, Mike,
and Eddie in treatment as well. Based on the discussion offered
by this
article, a relational approach to this traumatic event might
integrate
everyone’s experience, offer reconnection, and coach family
members

to adequately support James and each other. The traumatic event
had
a significant effect on everyone in the family, not only James.
As it turns
out, Eddie became afraid to venture out into the world. He grew
more
isolated and refused to take part in extramural activities at
school.
Alana incessantly blamed herself for what happened to James
and
began drinking more alcohol as a way to cope. In addition,
marital
arguments between Mike and Alana increased. The therapist’s
effort to
create a safe and affirming family environment is essential for a
process
of healing after such a violent traumatic event. This relational
trauma
treatment would address James’ symptoms individually to offer
coping
tools, while also guiding the family in their attempts to support
each
other and cope with the impact of trauma on each person and the
fam-
ily as a whole. The therapist would facilitate conversations to
help the
family talk together about the trauma for the first time. This
would be
a significant addition to the healing process for everyone,
fostering
safety and reconnection. These types of conversations are
emotional,
and require skill on the part of the therapist to keep all family
members
engaged and focused, while also helping them take a non-
blaming

stance. In addition, a skilled therapist with a systemic focus
would also
be able to address the marital and gender role issues
manifesting in
this family. An individually oriented approach for James would
miss
out on an opportunity for healing for everyone involved in the
system.
Practice
Trauma and its effects
Susan Johnson (2002) defines trauma as an event that occurs
‘when a person is confronted with a threat to the physical
integrity of
self or another, a threat that overwhelms coping resources and
evokes
subjective responses of intense terror, helplessness, and horror’.
(p. 14)
Traumatic stress is viewed as a mind-body condition, linking
physi-
ological and emotional responses (Van der Kolk, 2000).
As the clinical case example above illustrates, traumatic
experien-
ces often involve interpersonal violence. Herman (1997) refers
to
these experiences as violations of human connection. Even if

trau-
matic experiences do not involve interpersonal violence, they
often
evoke reactions of fear, terror, and helplessness (Foy et al.,
2001).
These experiences tend to violate an individual’s assumption
that the
world is a safe place making it a challenge to hold the traumatic
reality
in consciousness (Herman, 1997). As a result, survivors often
experi-
ence a profound sense of alienation and disconnection (van der
Kolk,
2003), impacting on their intrapersonal functioning and
relation-
ships. These emotions may cause survivors to feel isolated and
ques-
tion whether they are safe in the company of others or whether
others are really available to support them (Foy et al., 2001;
Matsakis,
2013). The disruption in interpersonal trust paired with the
conse-
quences of victimization, such as isolation and disconnection,
can
have a deep negative effect on the survivor’s overall quality of
life. In
order to hold a traumatic reality in consciousness and engage in
a
meaning-making process, an affirming and protective social
context
is necessary (Figley and Figley, 2009; Hawkins and Manne,
2013). For
a survivor, that context is created through relationships with
friends,
family, partners, and the community (Herman, 1997; Walsh,
2007).

Significant advances in the study of psychological trauma have
been made in the past few decades. PTSD is characterized by
intru-
sive re-experiencing symptoms, elevated arousal, and avoidance
behaviours (American Psychiatric Association, 2013). With the
grow-
ing understanding of the biological aspects of PTSD, it has
become
clear that exposure to trauma can produce long-lasting effects in
a
survivor’s endocrine and nervous systems. Individuals with
PTSD are
more likely to experience gastrointestinal problems, asthma, and
hypertension than those who do not have PTSD or elevated
PTSD-
type symptoms. PTSD can also become a chronic condition that
is fre-
quently comorbid with other mental health issues, such as
depression,
Practice
anxiety, and substance abuse (McLean and Foa, 2011). Further,
as
illustrated in the case of the Martin family, trauma and PTSD
does
not affect only the individual who experienced it but it impacts
on
and disrupts the lives of all the members of a family system
(Lebow

and Rekart, 2013).
Given the pervasive nature of PTSD and the individual and
societal
impact of trauma exposure, there is a growing body of research
and
treatment protocols for the treatment of trauma. Several
psychotherapy
approaches with strong empirical evidence have been developed
in the
past several decades to help with trauma recovery. However,
most of
these protocols are individually focused and do not directly
address sur-
vivors’ interpersonal struggles or take into account their
cultural back-
grounds or context. Recently there have been efforts to address
this
issue. For instance, in the UK, the National Institute of Clinical
Excel-
lence recommended interpreting trauma protocols to ensure
compe-
tent and culturally appropriate services for survivors of diverse
cultural
backgrounds and dominant languages (d’ Ardenne et al., 2007).
Fur-
ther, there has been an increased recognition of the effects of
trauma in
survivors’ relationships and family functioning. In medical care
in Vet-
erans Affairs settings in the USA, couple and family therapists
are slowly
becoming a valued part of the treatment of PTSD (Figley and
Figley,
2009).

Prominent individual therapy approaches
Although treating PTSD with pharmacology has accumulated
sup-
port, the Institute of Medicine considers trauma-focused
cognitive
behavioural therapy (TF-CBT) the first-level treatment for
traumatic
stress disorders (Institute of Medicine, 2008). The main goal in
TF-
CBT is for clients to face their traumatic memories instead of
avoiding
them, while also confronting thought patterns that reinforce the
avoidance of traumatic memories. The three most studied and
uti-
lized trauma protocols are exposure therapy, cognitive
processing
therapy (CPT), and eye movement desensitization therapy
(EMDR).
Exposure Therapy. Through repeated exposure to feared stimuli,
expo-
sure therapy promotes the extinction of the anxiety responses.
Expo-
sure therapy for the treatment of PTSD is based on the
behavioural
principle of fear acquisition. Treatment generally involves the
repeated confrontation of the feared thoughts, objects, or
situations
Practice

in order to reduce problematic fear and anxiety responses, such
as
physical and emotional avoidance (Carr, 2005; McLean and Foa,
2011). Prolonged exposure (PE) is the most widely used
exposure
therapy protocol due to its strong empirical support for the
reduction
of PTSD intrapersonal symptoms. PE incorporates
psychoeducation,
imaginal and in vivo exposure to feared stimuli, and training in
con-
trolled breathing (McLean and Foa, 2011).
Neuner et al. (2004) developed narrative exposure therapy
(NET), a
variant of EP, to address PTSD symptoms in survivors of mass
violence
and torture. NET draws from EP’s basic techniques and adds a
narra-
tive component. The narrative element aims to contextualize
trauma
as part of the survivor’s experience (McPherson, 2012). NET
places
emphasis on the reconstruction of the trauma memory by
incorporat-
ing a detailed narration of the traumatic events (Adenauer et al.,
2011).
Several researchers have found evidence to support the use of
NET for
the treatment of PSTD among survivors of mass violence
(Adenauer
et al., 2011; Neuner et al., 2004).
CPT. While CPT is not as well-researched as Exposure Therapy,
it

has been shown to be effective in the treatment of PTSD
symptoms
(Bradley et al., 2005), particularly for combat veterans with
chronic
PTSD (Monson et al., 2012). CPT is similar to PE in its use of
expo-
sure and psychoeducation but adds a written narrative form of
expo-
sure to change the survivor’s maladaptive thoughts over the
traumatic experience.
EMDR. EMDR is a CBT approach that involves exposure and
cogni-
tive processing with added simulation, usually in the form of
saccadic
eye movements (Solomon and Shapiro, 2008). The approach
begins
with the identification of symptoms that become triggered by
trau-
matic memories and focuses on reprocessing those traumatic
events
while also focusing on present triggers. Although there is some
debate
over the necessity of eye movements, EMDR treatment studies
have
found this protocol to be as effective as exposure therapy and
CPT
for the treatment of PTSD (Rogers and Silver, 2002).
The overall basic goals across individual trauma therapy
approaches are twofold: firstly, they aim to restore affect
regulation,
specifically with feelings of fear and anger. Secondly, trauma
therapy
interventions aim to integrate the traumatic experiences into an
empowered sense of self in order to engage in a meaning-

making
process (Figley and Figley, 2009; Johnson, 2002). Although
these are
Practice
two crucial elements in the survivor’s healing process, it is
difficult to
actively address the role of the healing environment and the
survi-
vor’s ability to re-establish connections with others in the
context of
individual therapy. Not addressing the systemic or relational
context
in which a survivor exists has several risks. Most notably, the
changes
that occur to the survivor may cause stressful occurrences in
their
context. For example, a survivor may become more assertive
because
of effective treatment. This newfound assertiveness may then
create
conflict in relationships so they shift or change. Interventions
that
bridge this process are very helpful. Another risk is not
providing the
survivor with the necessary social support they need to sustain
recov-
ery from trauma. Having a supportive array of intimate, family,
and
community relationships provides the needed support for

survivors
to sustain a recovery process. To cope with their trauma
survivors
often turn to substance use and other types of self-harming
behav-
iour. These coping strategies can sabotage effective trauma
recovery.
The usefulness of a systemic approach is clear In the case of the
Mar-
tin family, as shown above. Changing the systemic relationship
con-
text in which a survivor lives is a critical component of
sustained
recovery (Guay et al., 2006; Johnson, 2002). It is thus clear that
other
systemic or relational modalities are necessary to address the
complex
interpersonal issues that may arise in the aftermath of trauma.
Group therapy approaches
Group therapy is a widely utilized treatment for trauma
survivors, par-
ticularly with child sexual abuse (CSA) survivors and
adolescent survi-
vors of trauma (Classen et al., 2001; Saltzman et al., 2013).
However,
relatively few randomized controlled trials have examined the
efficacy
of group psychotherapy for trauma specifically. The existing
body of
research does suggest that group therapy is effective in reducing
depression, PTSD symptoms and dissociation, and improving
interper-
sonal skills and quality of life (Classen et al., 2001). Group
therapies

offer a safe space for the normalization of responses and
processing of
trauma among others who have similar experiences, giving
survivors
the opportunity to establish bonds and connections with others
(Foy
et al., 2001). Common across group intervention protocols is a
clear
emphasis on contextualizing symptoms and using the group
environ-
ment to decrease stigma and increase normalization and social
support.
Practice
Some studies report positive treatment effects for adults,
children
and adolescent survivors in group therapy protocols. However,
there is
no clear evidence of the superiority of any particular group
theoretical
approach or structure (Foy et al., 2001; Schnurr et al., 2003).
While the
case study example did not include group therapy as an
intervention,
it would have been useful for the individual in increasing
support and
in providing a safe place to process the traumatic experiences.
From a
systemic perspective, this approach on its own has limitations.

Couple and Family Therapy approaches
Trauma theorists agree that survivors need a safe place in order
to
stabilize the inner chaos caused by traumatic experiences and
work
on decreasing problematic trauma responses. Supportive
environ-
ments and people are indeed necessary to engage in this work;
however, Johnson (2002) posits that in order to be resilient in
the face
of trauma, survivors do not only need a sense of community,
they also
need ‘close attachment bonds’ (p. 27). Monson et al. (2012) also
say
that intimate relationships can play an important role in
recovery
from post-traumatic stress and its comorbid intrapersonal and
interpersonal impairments.
Henry et al.’s (2011) research finds that couple relationships are
affected when there is a history of trauma in one or both
partners. In
their study, participants identified a wide range of issues that
affected
their relational functioning including boundary issues, intimacy
prob-
lems and confusion about roles in the relationship, among
others.
The researchers suggest that not addressing these symptoms in
treat-
ment may exacerbate both the individual and relational distress
trauma survivors and their families may be experiencing. In the
case of
the Martin family, the traumatic event directly happened to the
cou-

ple’s son; however, the event was so extreme, that it severely
impacted
on the couple’s relationship as well as on individual
functioning. Not
addressing how such a violent event affects the couple
relationship
may exacerbate individual and relational distress.
Although there is a dearth of literature exploring relational
trauma
interventions, some treatment protocols have demonstrated it
has
positive results, for instance, in the use of CBT for couples in
which
one of the partners is a combat veteran diagnosed with PTSD
(Mon-
son et al., 2012). The CBT protocol for couples included
psychoedu-
cation about the ‘reciprocal influences of PTSD symptoms and
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relationship functioning’ (p. 702), strategies to create a shared
sense
of safety, and problem solving and decision-making skills.
Research-
ers found that this protocol ameliorated PTSD symptoms as well
as
relationship satisfaction.
Emotionally Focused Therapy (EFT) is an attachment-based

cou-
ple therapy that emphasizes the role of affect and emotion in
thera-
peutic change (Johnson, 2002). Trauma survivors often
experience
difficulty re-establishing connections, and research indicates
that con-
nection and safety are critical in trauma healing (Herman,
1997).
There is some empirical support for EFT’s treatment of general
cou-
ple distress and Johnson (2002) asserts that EFT’s attention to
estab-
lishing and maintaining a safe and secure attachment bond
between
partners is vital in creating a healing environment in the
aftermath of
trauma.
A recent study examined the effectiveness of EFT in couples
where
one of the partners was a survivor of CSA (Dalton et al., 2013).
The
study’s findings suggest that the link between childhood trauma
and
marital outcomes could be mediated by the ability to form
secure
attachments with others (Whisman, 2006). Participants in
Dalton
et al.’s (2013) study demonstrated an increase in relationship
satisfac-
tion over time and an improvement in marital functioning. The
results suggest that EFT offers a viable option for helping
clients
reconnect with significant others and further their progress in
recov-

ery and healing.
Kerig and Alexander (2012) propose the integration of trauma
com-
ponents to Functional Family Therapy (FFT), an evidence-based
model, in the treatment of traumatized youth involved in the
juvenile
justice system. The authors indicate it is importance to address
the
effects of these traumatic experiences in the context of the
family sys-
tem. Families can foster sources of resilience such as
connectedness,
affection, and bonding, essential for trauma healing. Trauma-
focused
FFT frames the traumatic experience in relational terms that
recognize
that all family members are affected by trauma, even if only one
mem-
ber directly experienced the traumatic event.
Multi-family group interventions based on behavioural and
skill-
building components have strong empirical support in
enhancing
family functioning and connection (McFarlane et al., 2004).
Although there are limited empirically supported interventions
for
distressed families exposed to trauma or living in traumatic con-
texts, Kiser et al. (2010) proposed a multi-family group
intervention
that builds on families’ resources to enhance the coping
mechanisms

Practice
and protective factors that may mediate the effects of trauma
expo-
sure. This trauma-focused intervention based in empirically
sup-
ported treatment components has positive effects on post-
traumatic
symptoms.
The approaches described all include family or relationships as
a
part of the treatment for trauma survivors. Their broad goals are
to
increase positive support and connection among family
members,
create safety, and reduce negative interactional cycles. These
approaches have a growing body of evidence showing their in
reduc-
ing the effects of trauma symptoms in survivors in some cases.
As in
the case of the Martin family, a traumatic event, may even have
severe
repercussions on other members of the family. A treatment
approach
that attends to the needs of all family members while fostering a
sup-
portive and safe environment is essential to reconnection and
healing.
Unique elements among relational trauma interventions
We reviewed systemic treatments with an eye on their

commonalities
in strategies and change mechanisms. Families often avoid
discussing
trauma, leaving survivors and family members feeling isolated
and
disconnected from vital sources of support (Coulter, 2013).
Although
there are a limited number of relational interventions for
trauma, the
existing protocols contain two unique elements that are rarely
addressed through individually focused therapy alone, primarily
because the latter attend mostly to the intrapersonal impact of
trauma.
The first core element of relational interventions for trauma is
the
psychoeducational component aimed at enhancing each family
mem-
ber’s understanding of how trauma affects individual and family
func-
tioning (Coulter, 2013; Kerig and Alexander, 2012; Monson et
al.,
2012). This education serves to normalize the experiences of
family
members and to address issues of communication over
symptoms and
coping. Further, those conversations can provide an opportunity
for
members to co-create the meaning of the experience, facilitating
heal-
ing (Coulter, 2013). A contextualized and relational approach to
treat-
ing the Martin family would provide opportunities for the
family to
talk about how the trauma affected each individual in the
family, nor-

malizing individual responses while fostering reconnection.
Psycho-
education offered in the context of a relational treatment
provides a
Practice
way to increase a sense of competency and normalcy, improve
coping
strategies, and increase support among family members (Rabin
and
Apel, 2013).
Closely related is the second significant element in relational
approaches for trauma: attention to a process of reconnection
and
bonding within the system. Catherall (1999) discusses the
impor-
tance of facilitating the family’s support of the traumatized
member
by helping the entire system to function as a team in dealing
with
the aftermath of trauma. The interaction between the individuals
who directly experience trauma and the rest of the family is
recip-
rocal in nature (Coulter, 2013), suggesting a strong potential for
the
family to affect the course of recovery. This reconnection
process
would support the Martin family and others like it, not only by
increasing the positive social bonds in the family but also by

allow-
ing the family to grow in step with the survivor, who invariably
experiences significant life changes because of effective trauma
treatment.
Post-traumatic growth (PTG)
An important part of expanding our understanding of trauma
and its
aftermath is recognizing that survivors often report experiences
of
positive change in their struggles with adversity. In the last few
deca-
des, the trauma literature has used different terminologies to
describe
this phenomenon, such as PTG (Tedeschi and Calhoun, 1996)
and
adversity-activated development (Papadopoulos, 2007).
Tedeschi and
Calhoun (1996) describe PTG as ‘positive psychological change
expe-
rienced as a result of the struggle with highly challenging life
circum-
stances or traumatic events’ (p. 1). As a result of PTG,
individuals
often report a greater appreciation for life, changes in life
philosophy,
changes in their self-view, including a greater sense of personal
strength, and an enhancement in their personal relationships.
Papa-
dopoulos (2007) proposed a ‘trauma grid’ to identify the various
con-
sequences of traumatic experiences at the individual, family,
community and societal levels in order to address the effects of
trauma more appropriately by avoiding oversimplification and
polarization.

These potential experiences of positive change and growth have
a
profound impact on survivor’s close relationships. Thus, the
inclusion
these relationships in treating trauma seems profoundly relevant
Practice
when considering the influence of the individual’s environment
in
their recovery, healing and growth processes. As an individual
grows,
relationships change and grow as well. Following a traumatic
event,
particularly one that involves violence, as in the case of the
Martin
family, safety within relationships needs to be restored as a part
of the
recovery process. Fostering tolerance within families of the
survivor’s
erratic fluctuations from instances of closeness to moments of
distance
during the recovery process is critical for successful recovery.
It is
within the safety of relationships and close connections that
survivors
are able to reintegrate the trauma information into a cohesive
narra-
tive, leading to growth and healing.

Most of the research on PTG has focused exclusively on
individual
experiences, without paying much attention to the impact of
their
social supports (Büchi et al., 2009). However, in a study of
couples
coping with cancer, Kunzler et al. (2014) found that support
from an
intimate partner plays a critical role in a patient’s adjustment.
The
study shows that couples not only share the burden of a cancer
diag-
nosis, they may also share the potentially positive benefits.
These
findings suggest that the influence of a couple’s joint benefit
and
growth experience may be a powerful force in recovery and
adjust-
ment. Büchi et al. (2009)’s study on grief processes in couples
after
the death of their premature baby shows that the emotional
exchange
between partners after their loss may be vital for a process of
shared
and concordant grief. The results of the study suggest that in
con-
cordant grief processes both partners also share a process of
growth.
A systemic approach to understanding the negative, positive and
neutral psychological effects of trauma is vital to explore
whether
PTG is not only an individual experience, but can also be a
relational
occurrence. More research is needed to understand the
complexity

of this phenomenon, including the interactive effects on
individual
and relational PTG.
Challenge to the field of systemic or relational therapies
Trauma survivors often experience a sense of betrayal and
distrust in
the wake of traumatic events. It is, therefore, appropriate to
concep-
tualize trauma as a family event, something that affects the
individual
who directly experiences the traumatic event and their most
intimate
relationships in social and cultural contexts. Further, as Bracken
(2001) asserts, if contextual issues are central in determining
how
Practice
trauma is experienced, developing supportive environments
condu-
cive to healing and reconnection is essential. Although
individualized
approaches that address problematic traumatic stress symptoms
are
necessary, wider systemic approaches that incorporate the
possibility
of experiencing individual and relational growth following the
trau-
matic event and that emphasize the individual’s environment

and
relationships are fundamental for healing.
Noted trauma experts such as Herman (1997), Bracken et al.
(1995),
Bracken (2001) and Johnson (2002), suggest that connection
with
others is at the heart of trauma healing. Recovering from trauma
involves helping the survivor reorganize their intrapsychic
world
through the creation of new safe and affirming interpersonal
connec-
tions. However, there is limited empirical support for trauma-
focused
group approaches. Similarly, there are few studies that explore
couple
therapy and family therapy trauma-focused modalities, even
though
the initial evidence is very promising. Emotional attachment is
consid-
ered as one of the primary protection mechanisms against
feelings of
hopelessness and meaninglessness (McFarlane and Van der
Kolk,
1996). It therefore seems clear that improving individuals’
closest rela-
tionships and understanding how those relationships can be a
source
of strength and healing can be a crucial element in addressing
the
problems that affect trauma survivors’ physical and mental
health.
When discussing the effects of trauma, theorists, clinicians, and
researchers all agree that the presence of post-traumatic stress
primar-

ily affects the individual’s ability to process traumatic
experiences
(Boss, 2006; Herman, 1997; Van der Kolk, 2000). As noted
earlier, this
individual process affects and is affected by relationships.
However,
barriers remain for relational or systemic-oriented treatments to
become fully integrated into widely used trauma-focused
treatment
protocols. This is because, even though there is research
pointing to
the initial efficacy of these interventions as a core and
adjunctive treat-
ment, not enough efforts have been made to increase the scope
of this
research or to prioritize its importance globally. In addition,
there is a
need for increased advocacy efforts to publicize these
interventions
worldwide as core healing strategies. There is a need for further
research to expand our understanding of how trauma manifested
within couple and family relationships and how treatment
interven-
tions can address these challenges in a strength-based,
supportive envi-
ronment that facilitates healing. Further, McLean and Foa
(2011)
found that most therapists do not use evidence-based treatments
for
PTSD due to a lack of training. These findings call for the
better
Practice

dissemination of protocols, particularly for clinicians working
with
trauma in the context of couple or family therapy.
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717
JRRDJRRD Volume 49, Number 5, 2012Pages 717–728
Couple/family therapy for posttraumatic stress disorder: Review
to

facilitate interpretation of VA/DOD Clinical Practice Guideline
Candice M. Monson, PhD;1–2* Alexandra Macdonald, PhD;3
Amy Brown-Bowers1
1Ryerson University, Toronto, Ontario, Canada; 2Department of
Veterans Affairs (VA) National Center for PTSD,
Women’s Health Sciences Division, Boston, MA; 3VA National
Center for PTSD, Behavioral Science Division, and
Boston University School of Medicine, Boston, MA
Abstract—A well-documented association exists among Vet-
erans’ posttraumatic stress disorder (PTSD) symptoms, family
relationship problems, and mental health problems in partners
and children of Veterans. This article reviews the recommenda-
tions regarding couple/family therapy offered in the newest
version of the Department of Veterans Affairs (VA)/Depart-
ment of Defense (DOD) VA/DOD Clinical Practice Guideline
for Management of Post-Traumatic Stress. We then provide a
heuristic for clinicians, researchers, and policy makers to con-
sider when incorporating couple/family interventions into Vet-
erans’ mental health services. The range of research that has
been conducted on couple/family therapy for Veterans with
PTSD is reviewed using this heuristic, and suggestions for
clinical practice are offered.
Key words: caregiver burden, clinical practice guidelines,
cognitive-behavioral therapy, couple/family therapy, emotion-
ally focused couple therapy, mental health, PTSD, rehabilita-
tion, strategic approach therapy, Veterans.
INTRODUCTION
To their credit and our benefit, Veterans and their fami-
lies have been the predominant contributors to our knowl-
edge about the role of posttraumatic stress disorder (PTSD)
symptoms in family functioning and vice versa. This

research documents a clear and convincing association
between PTSD symptoms and a range of family problems
(see Monson et al. [1] for review). In addition, Veterans’
PTSD symptoms have been associated with a myriad of
individual mental health problems in spouses and children
(see Renshaw et al. [2] for review). Yet, research on couple/
family therapies for Veterans with PTSD has lagged behind
individual psychotherapy treatment outcome efforts. This is
in spite of research showing that Veterans desire greater
family involvement in their treatment (e.g., Batten et al. [3])
and the presence of significant mental health problems in
Veterans’ loved ones who may individually profit from
family therapy. In addition, treatments for PTSD do not
necessarily improve couple and family functioning (e.g.,
Abbreviations: BCT = behavioral couple therapy, BFT =
behavioral family therapy, CBCT = cognitive-behavioral con-
joint therapy, CPG = Clinical Practice Guideline, CSO = con-
cerned significant other, DOD = Department of Defense, DTE =
directed therapeutic exposure, EFCT for Trauma = emotionally
focused couple therapy for trauma, LMC = lifestyle manage-
ment course, PTSD = posttraumatic stress disorder, RCT = ran-
domized controlled trial, SAFE = Support and Family
Education (Program), SAT = strategic approach therapy, VA =
Department of Veterans Affairs.
*Address all correspondence to Candice M. Monson, PhD;
Department of Psychology, Ryerson University, 350 Victoria
St, Toronto, ON M5B 2K3 Canada; 416-979-
Email: [email protected]
http://dx.doi.org/10.1682/JRRD.2011.09.0166
718

JRRD, Volume 49, Number 5, 2012
Glynn et al. [4]; Lunney and Schnurr [5]; Monson et al.*)
and negative family interactions have been associated with
poorer individual cognitive-behavioral treatment outcomes
[6–7]. To further treatment and research efforts in this area,
this article reviews the recommendations regarding couple/
family therapy offered in the newest version of the
Department of Veterans Affairs (VA)/Department of
Defense (DOD) VA/DOD Clinical Practice Guideline for
Management of Post-Traumatic Stress. [8] and then pro-
vides a heuristic for clinicians, researchers, and policy
makers to consider when incorporating couple/family
interventions into Veterans’ mental health services. Then,
the range of research that has been conducted on family
therapy for PTSD with Veterans is reviewed using this
heuristic and suggestions for clinical practice are offered.
METHODS
Recommendations regarding couple/family therapy
offered in the newest version of the VA/DOD Clinical Prac-
tice Guideline for Management of Post-Traumatic Stress
were reviewed. Review of the empirical studies on which
these guidelines were based resulted in the development
of a heuristic that organizes these interventions based
on an interaction of their stated focus of improving
(1) relationship functioning and/or (2) PTSD. Following
this, a literature search was done on couple/family inter-
ventions for PTSD using PsychInfo, MEDLINE, ERIC
(Education Resources Information Center), and Google-
Scholar databases. The following search terms were used:
couple therapy, conjoint therapy, family therapy, interper-
sonal, PTSD, and trauma.
RESULTS

Couple/Family Therapy
In the clinical practice guideline (CPG) , family therapy
was given an overall “Insufficient” rating for the treatment
of PTSD; this rating indicates “The evidence is insufficient
to recommend for or against routinely providing the inter-
vention. Evidence that the intervention is effective is lacking
or poor quality, or conflicting, and the balance of benefits to
harms cannot be determined” [8, p. 202]. The supporting
evidence offered for this conclusion includes three studies:
Devilly [9], Glynn et al. [4], and Monson et al. [10]. Upon
review of these studies, the CPG summarizes that “BFT
[behavioral family therapy] did not significantly improve
the PTSD symptoms and was inferior to other psychothera-
pies” [8, p. 144]. The level of evidence was rated as “I = At
least one properly done RCT [randomized controlled trial],
“and the quality of evidence was rated ‘fair-poor.’” The
CPG concludes “There is insufficient evidence to recom-
mend for or against Family or Couples Therapy as a first-
line treatment for PTSD. Family or Couples therapy may be
considered in managing PTSD-related family disruption or
conflict, increasing support, or improving communication”
[8, p. 118].
Although we agree with the ultimate overall “I” rat-
ing and subratings of level and strength of evidence, we
disagree with the conclusion drawn from the studies
reviewed. In addition, there are other studies not consid-
ered in the CPG that we believe are important to consider
when drawing a conclusion about the benefits and costs
of couple/family therapy for PTSD, which we systemati-
cally review in the next section. Our concerns with the
conclusion offered from the literature reviewed in the

CPG are outlined here.
Glynn et al. conducted one of the most rigorous tests
of family therapy for PTSD to date [4]. In their study, they
used an additive research design to test the incremental
utility of a specific BFT focused on improving communi-
cation and problem-solving skills [11]. In this trial, the
provision of BFT followed an individually delivered
psychotherapy, directed therapeutic exposure (DTE),
which focused on repeated narrative trials and cognitive
restructuring of two traumatic memories [12]. Forty-two
Veterans and one of their family members (89% conjugal
waiting list. Outcomes reported were clinician-rated PTSD
symptoms and patient and family member reports of fam-
improved more than those assigned to the waiting list on
what the authors refer to as “positive” PTSD symptoms
(i.e., reexperiencing, hyperarousal) but not the “negative”
symptoms of PTSD (i.e., avoidance, numbing) or social
showed statistically significantly more improvements in
*Monson CM, Macdonald A, Vorstenbosch V, Shnaider P,
Goldstein
ESR. Changes in social adjustment with cognitive processing
therapy: effects of treatment and association with PTSD
symptom
change. J Trauma Stress. 2012. In press.
http://www.rehab.research.va.gov/jour/2012/495/pdf/VADODcli
nicalguidlines495.pdf

719
MONSON et al. Couple/family treatments for PTSD
interpersonal problem-solving than did participants who
received DTE only. When interpreting the results of this
trial, note that BFT followed individual DTE; BFT alone
was not directly compared with DTE.
The two other studies on which the CPG was based
were uncontrolled trials that did not include randomization
or a control or comparison condition. They generally did not
include methodologically rigorous elements of controlled
psychotherapy studies, such as independent and blinded cli-
nician assessment of PTSD symptoms, assessment of
longer-term outcomes, fidelity to treatment assessment,
or reliability assessment of clinician assessors. Devilly
described the results of a program evaluation study of Aus-
tralian combat Veterans and their partners who participated
in an intensive weeklong residential group intervention that
included psychoeducation about PTSD and symptom man-
agement techniques [9]. At follow-up, both Veterans and
their partners reported statistically significant reductions in
anxiety, depression, and general stress; Veterans reported a
significant reduction in PTSD symptoms. Small and nonsig-
nificant improvements were also observed for anger and
quality of life, but not for relationship satisfaction.
The other study tested an early version of cognitive-
behavioral conjoint therapy (CBCT) for PTSD [13], which
is designed to simultaneously ameliorate PTSD symptoms
and enhance relationship functioning. In a sample of seven
couples in which one member of the couple was a male
Vietnam Veteran with PTSD, Monson et al. found statisti-

cally significant and large effect size improvements in clini-
cians’ and partners’ ratings of Veterans’ PTSD symptoms
from pre- to posttreatment [10]. The Veterans reported
moderate effect size improvements in PTSD and statisti-
cally significant and large improvements in depression,
general anxiety, and social functioning. Wives reported
large effect size improvements in their relationship satisfac-
tion, general anxiety, and social functioning [14].
Based on a review of these three studies (and other
studies completed to date), no couple/family therapy has
ever been directly compared with another psychotherapy
for PTSD. Thus, given the available evidence, it is not
possible to conclude that couple/family therapy alone is
inferior to other therapies as indicated in the CPG. More-
over, Devilly [9] and Monson et al. [10] found significant
improvements in PTSD symptoms as a result of a partner-
involved treatment. We think a more accurate conclusion
might be that some evidence suggests that the class of
cognitive-behavioral couple interventions may improve
PTSD symptoms and intimate relationship functioning.
Heuristic for Understanding Treatment Targets
The CPG’s recommendation regarding couple/family
therapy underscores one consideration when evaluating
couple/family treatments for PTSD: What is the treatment
target? Is it improvements in family functioning? PTSD
symptoms? Both? To further policy, practice, and research
in this area, we offer a heuristic to consider when making
decisions about how to incorporate family members into
Veterans’ treatment (Figure). This heuristic organizes
interventions based on an interaction of their stated focus
of improving (1) relationship functioning and/or (2) PTSD.
All the interventions discussed in this article fall into the
broader category of couple/family therapy in that they

address the close relational system in which the individual
exists. Our heuristic expands Baucom et al.’s [15] prior
conceptualization of empirically supported couple and
family interventions for marital distress and adult mental
health problems by considering the range of concerned
significant others (CSOs) such as parents, siblings, close
friends, and extended family who might be considered
“family” by the patient and included in treatment to
enhance its efficacy (i.e., not just focused on couple dis-
tress). Drawing on research in the substance use disorder
literature documenting the use of CSOs in treatment
engagement [16], we also consider interventions that are
not designed to explicitly improve PTSD or another mental
health condition or relationship functioning, but may be
used to enhance treatment delivery by increasing engage-
ment or facilitating the provision of other treatments.
The specific objectives and hoped-for outcomes of
these interventions differ based on the way that family is
Figure.
Heuristic for understanding target of different couple/family
inter-
ventions for posttraumatic stress disorder (PTSD).
720
included; the interventions differ based on their focus on
the relationship and/or PTSD symptoms. In addition,
some of these interventions have also yielded improve-
ments in family members’ health and well-being. Some

interventions specifically target the marital- or romantic
relationship within the family (i.e., couple therapy), while
others include other family members. We have attempted
to refer to the format (i.e., couple or family) of therapy as
described in the publications by the authors. The mini-
mum inclusion criterion for review was objective data
analyzed at the group level; theoretical writings and indi-
vidual case studies were not included in this review.
First, as demonstrated in the lower right-hand quad-
rant of the Figure, family members may be used to
engage Veterans in assessment and treatment or to edu-
cate them about PTSD and the rationale of evidence-
based treatments. In this way, improvements in PTSD
symptoms or relationship functioning are not the targets
of the intervention; rather, engagement and/or education
are the goals. These interventions may include strategies
taught to CSOs to increase the likelihood of Veterans
seeking treatment for PTSD and its common comorbidi-
ties and/or education provided to CSOs about the symp-
toms of PTSD and the rationale for various evidence-
based treatments.
Second, family members may be involved in what we
term “generic family therapy” with the Veteran. This
approach has the parsimonious goal of improving relation-
ship functioning. Improvements in relationship functioning
may, in fact, improve a Veteran’s PTSD symptoms and the
health and well-being of family members by decreasing the
stress in their interpersonal environment. However, the
objective of the family members’ inclusion is to improve
the relational milieu in which the Veteran and his or her
family exist and does not specifically target the mecha-
nisms thought to maintain the individual disorder.
Third, family members may be involved in partner-

assisted interventions in which the family members serve
as a surrogate coach or therapist for the Veteran. These
interventions aim to promote the Veteran’s treatment by
educating family members about the rationale for therapy
so that they can actively support the Veteran in treatment
or enhance therapies typically delivered in an individual
format. Relational issues are not the focus of these inter-
ventions; supported delivery of the individual interven-
tions is the goal.
Fourth, family members may be included in disorder-
specific family therapies, which are therapies that have
been specifically developed to simultaneously improve
relationship functioning as well as PTSD. In this way,
relationship functioning and individual-level symptoms
of PTSD are simultaneous targets for the interventions.
To be maximally efficient in the therapy, the interven-
tions are generally developed to target mechanisms
known to contribute to the development and maintenance
of PTSD and relational distress.
Efficacy of Interventions by Type of Involvement
Strategy
The Table includes a summary of evidence regarding
treatment efficacy related to the stated treatment target
(i.e., individual PTSD outcome and/or relationship adjust-
ment outcome). Consistent with the description above, we
begin with those interventions designed to improve treat-
ment engagement in assessment and treatment of PTSD or
knowledge about PTSD.
Education Program

The Support and Family Education (SAFE) Program is
a multisession educational program for families dealing
with a wide range of mental illnesses (e.g., PTSD, major
depression, bipolar disorder, schizophrenia) [17]. The inter-
vention involves various family members (e.g., spouse,
parent, siblings) in 14 sessions of educational material
covering a range of topics for loved ones of a person with a
mental illness and 4 sessions of skills training in problem-
solving and minimizing stress. Because this is an educa-
tional program, the material is provided in once monthly
90 min workshops and attendance is based on family mem-
ber interest. In a 5 yr program evaluation, Sherman et al.
reported that participant satisfaction was 18.2 out of a pos-
sible score of 20 (highest satisfaction) [18]. Caregivers
attended a mean of 6.3 sessions; Sherman et al. noted that,
given the monthly meeting schedule, they had a high rate of
retention [18]. PTSD-focused sessions were the most well-
attended sessions within the series, and 53 percent of care-
givers of a loved one with PTSD attended more than one
session. Finally, Sherman and colleagues reported positive
correlations between the number of sessions attended and
the understanding of mental illness, awareness of VA
resources, and ability to engage in self-care activities.
Negative correlations were found between the number of
sessions attended and caregiver distress. No data regarding
patient PTSD or other mental health outcomes for the fam-
ily members or Veterans were reported.
721
Table.
Couple/family interventions for posttraumatic stress disorder

(PTSD).
Intervention Brief Description Key Citation
Education and Engagement
Support and Family Education
(SAFE) Program
SAFE Program is multisession educational program for families
dealing
with wide range of mental illnesses (e.g., PTSD, major
depression, bipolar
disorder, schizophrenia). Program welcomes various family
members
(e.g., spouse, parent, siblings). Includes 14 sessions of
educational mate-
rial covering range of cogent topics for loved ones of person
with mental
illness and 4 sessions of skills training in problem-solving and
minimizing
stress. Material is provided in once monthly 90 min workshops
and atten-
dance is based on family member interest. Little objective data
reported on
SAFE program; however, family members reported high
satisfaction with
program in one study and anecdotal reports indicate skills
learned helped
participants’ families.
Sherman, 2003 [17];
Sherman et al., 2006 [18]
Engagement No empirical data on interventions specifically
targeting concerned sig-
nificant others to facilitate treatment engagement.

Not applicable
Generic Couple/Family Therapy
Therapy (BCT/BFT)
In randomized clinical trial, Glynn et al. tested version of BFT
following
individual cognitive-behavioral therapy [4]. This family
treatment
included (1) psychoeducation on PTSD that explicitly addresses
relatives’
expectations and coaches them on recognizing and reinforcing
intermedi-
ate gains in service of long-term progress and (2) skills training
in
communication (i.e., constructive expression of feelings and
empathic
listening), problem-solving, and anger management training.
BFT was
delivered in 8 weekly 2 h sessions. Those receiving BFT and
individual
therapy evidenced significantly better interpersonal problem-
solving skills
than those receiving individual therapy only. BCT tested in
other studies
included goals of increasing positive interactions, improving
communica-
tion, teaching problem-solving skills, and enhancing intimacy in
intimate
partners. These studies have generally revealed significant
improvements
in relationship functioning, but less effects on individual PTSD
symptoms.
Glynn et

Sweany, 1987 [40]
K’oach Program K’oach program was monthlong, extensive,
multifaceted treatment pro-
gram developed in Israel. Wives of male Veterans were included
at several
points during program to learn communication skills, cognitive
coping
skills, and reinforcement methods to support husbands’ positive
behavior.
Wives and family members participated in “family day” that
included
entertaining activities and increased positive interactions.
During last 2 wk
of program, Veterans and wives participated in three couple
groups during
which they discussed common problems, improved
communication and
problem-solving skills, and promoted Veterans to view their
partners as
sources of support. These groups continued after treatment and
served as
self-help group. Little empirical research has been reported on
efficacy of
program. Some evidence that K’oach program improved
relationship
functioning, but not Veterans’ PTSD symptoms.
Rabin & Nardi, 1991
[26]; Solomon et al.,
1992 [27]
Partner-Assisted Interventions
Lifestyle Management Course

(LMC)
LMC is intensive, structured group intervention for Veterans
and their partners
that consisted of 5 d of courses in residential setting led by
counselors experi-
enced in treating Veterans with PTSD. Intervention is based on
cognitive-
behavioral principles and conceptualizations of PTSD and was
delivered to
both members of couple simultaneously. Topics covered
included education
about PTSD, relaxation/meditation, self-care, diet and nutrition,
alcohol use,
stress management, communication, anger management, and
problem-
solving. In one study, program was shown to reduce anxiety,
depression, and
stress in both Veterans and their partners and PTSD symptoms
in Veterans.
Has not been shown to improve relationship satisfaction.
Devilly, 2002 [9]
722
Currently, no published research that we are aware of
has investigated the use of CSOs to engage Veterans with
PTSD into treatment. Given the number of barriers that
exist for Veterans with PTSD to present for assessment and
treatment [19] and the number of CSOs who want to help
but may not know the best way to help and/or may “help”
in inadvertently detrimental ways (e.g., accommodation or

codependent behaviors), this is an important way of utiliz-
ing family members in order to enhance service delivery.
We are aware of at least one national effort, called “Coach-
ing Into Care,” that is a telephone-based support service
designed to help family members of Veterans encourage
distressed Veterans to access their VA healthcare benefits.
The focus of the service is specifically in cases of mental
health issues. The intervention is designed to provide sup-
port to family members and help them plan and implement
an informed, noncoercive approach when talking with a
troubled Veteran about seeking or resuming VA mental
health care. Initial program evaluation data suggest a modest
increase in the engagement of the Veteran in mental health
care after one or several telephone coaching sessions [20].
Generic Couple/Family Therapy
Behavioral couple/family therapy. In this article, we use
the acronym BCT when referring to studies involving cou-
ples only and BFT for those studies involving a range of
Intervention Brief Description Key Citation
for Trauma)
EFCT for Trauma is short-term (12 to 20 sessions), experiential
intervention
with focus on identifying and processing emotions connected to
traumatic
experiences. Treatment also aims to understand how these
emotions are
related to broader attachment behaviors and styles and how they
affect rela-

tional processes and communication. EFCT for PTSD is divided
into three
main stages that focus on (1) stabilizing family through
assessment, identifi-
cation, and sharing of negative interaction patterns; (2) building
relational
skills in couple through acceptance and communication; and (3)
integrating
therapeutic gains and planning through development of coping
strategies
and positive interaction patterns. Study of adult female sexual
abuse victims
and male partners found improvements in PTSD symptoms and
clinically
significant improvements in half the couples’ relationship
satisfaction.
Johnson, 2002 [28];
MacIntosh & Johnson,
2008 [29]
(SAT)
SAT is 10-session intervention aimed at reducing effortful
avoidance and
emotional numbing symptoms of PTSD. SAT combines partner-
based anxi-
ety reduction, behavior exchange, and stress inoculation
techniques to gradu-
ally increase couples’ exposure to anxiety-producing, avoided
situations and
positive emotional exchanges. Three broad treatment phases are
(1) motiva-
tional enhancement and psychoeducation about PTSD,

specifically avoid-
ance symptoms and their effect on relationships; (2)
relationship
enhancement and increased emotional intimacy; and (3) partner-
assisted
anxiety reduction using graded exposures. Initial results from
uncontrolled
trial found improvements in behavioral avoidance and emotional
numbing;
no data reported regarding relationship satisfaction effects.
Sautter et al., 2009 [30]
Cognitive-Behavioral Conjoint
for PTSD)
CBCT for PTSD is designed to simultaneously improve
individual PTSD
symptoms and enhance intimate relationship functioning. CBCT
for PTSD
consists of fifteen 75 min sessions comprising three phases: (1)
education
about PTSD and its effect on relationships and safety building,
(2) com-
munication skills training and couple-oriented in vivo exposures
to over-
come behavioral and experiential avoidance, and (3) cognitive
interventions aimed at changing problematic trauma appraisals
and beliefs
that maintain PTSD and relationship problems (i.e., trust,
power/control,
and emotional and physical closeness). Data from uncontrolled
trials with
Veteran and community samples and initial results from
randomized con-

trolled trial of range of traumatized individuals provide
evidence for
improved PTSD symptoms, improved relationship satisfaction
(especially
in partners), and enhanced partner mental health and well-being.
Monson et al., 2005 [6];
Monson & Fredman,
2012 [13];
Schumm et al., 2011*
*Schumm JA, Fredman SJ, Monson CM, Chard KM. Cognitive-
behavioral conjoint therapy for PTSD: Initial findings for
Operations Enduring and Iraqi Freedom
male combat veterans and their partners. Am J Fam Ther. 2012.
In press.
Table. (cont)
Couple/family interventions for posttraumatic stress disorder
(PTSD).
723
family members. Whether applied to couples or families
more broadly, behavioral couple/family therapy (BCT/BFT)
generally involves behavioral exercises to increase positive,
reinforcing exchanges in couples and families, as well as
communication skills training (i.e., sharing thoughts and
feelings, problem-solving) [21]. Some interventions include

a cognitive focus on partners’ maladaptive standards and
attributions applied to the relationship and to each other
[22]. BCT has been identified as an efficacious practice for
general couple distress according to American and Canadian
Psychological Association Treatment Guidelines [23–24].
Two completed RCTs have tested variants of generic
BCT/BFT with PTSD patients. Both were conducted with
samples of male combat Veterans and their family mem-
bers. As previously reviewed, in another published RCT
including BFT after DTE, Glynn and colleagues found
improvements in interpersonal problem-solving than
those who did not receive BFT [4].
Three other uncontrolled studies have examined group
BCT with Veterans. Cahoon reported the results of a 7 wk
group BCT focused on communication and problem-
solving training for male combat Veterans and their female
partners [25]. Group leaders reported statistically signifi-
cant improvements in Veterans’ PTSD symptoms and cop-
ing abilities, and female partners reported significant
improvements in marital satisfaction and problem-solving
communication. The Veterans did not report improvements
in problem-solving or emotional communication skills.
K’oach program. Results have been reported from the
Israeli K’oach program, an intensive treatment program
for male combat Veterans with PTSD in which wives were
included at several points during the program [26–27].
This program included psychoeducation about PTSD,
plus communication and problem-solving skills training
for the couples. Minimal outcome data have been reported
on this intervention; however, 68 percent of the male Vet-
erans and their wives reported relationship improvements.
Consistent with the focus of the intervention, no decreases

in Veterans’ PTSD symptoms were observed.
Partner-Assisted Interventions: Lifestyle Management
Course
As discussed, Devilly described the results of an
uncontrolled study of Australian combat Veterans and
their partners who participated in an intensive weeklong
residential group intervention that included psychoeduca-
tion about PTSD and symptom management techniques
[9]. At follow-up, both Veterans and their partners
reported significant reductions in anxiety, depression,
and general stress and Veterans reported a significant
reduction in PTSD symptoms. Small improvements were
also observed for anger and quality of life but not for rela-
tionship satisfaction.
Disorder-Specific Interventions
Emotionally focused couple therapy for trauma. Emo-
tionally focused couple therapy for trauma (EFCT for
Trauma) is a short-term (12 to 20 sessions), experiential
intervention with a focus on understanding and processing
emotions that are connected to the traumatic experience and
broader attachment behaviors and styles that affect relational
processes and communication [28]. EFCT for Trauma is
divided into three main stages that focus on (1) stabilizing
the couple through the assessment, identification, and shar-
ing of negative interaction patterns; (2) building relational
skills in the couple through acceptance and communication;
and (3) integrating therapeutic gains and planning through
development of coping strategies and interaction patterns.
Qualitative case studies are reported in Johnson [28].
A study of 10 couples, including an adult female who

had suffered child sexual abuse, provides initial support for
the efficacy of EFCT for Trauma [29]. In this study, the
couples completed between 11 and 26 sessions of therapy
and completed assessments at pre- and posttreatment. The
authors report that all the participants experienced at least
one standard deviation worth of improvements on a
clinician-administered measure of PTSD and half the
participants self-reported clinically significant improve-
ments in PTSD symptoms. Also, half the participants
self-reported clinically significant improvements in rela-
tionship satisfaction. Three couples who reported decreased
satisfaction and increased emotional abuse terminated
their relationships during the course of therapy. The
authors suggest that EFCT for Trauma may not be appro-
priate for couples in which emotional abuse exists.
Strategic approach therapy. Strategic approach therapy
(SAT) is a 10-session manualized BCT developed by
Sautter et al. [30] to target the avoidance/numbing symp-
toms of PTSD. Findings from six Veteran couples who
completed the intervention include significant improve-
ments in these symptoms according to patient, partner,
and clinician ratings. Significant improvements also
occurred in the Veterans’ total PTSD symptoms, but not
reexperiencing or hyperarousal symptoms. Relationship
adjustment also significantly improved [31].
724
Cognitive-behavioral conjoint therapy for posttraumatic
stress disorder. CBCT for PTSD is designed to simulta-
neously address individual PTSD symptoms and relation-

ship problems [13]. CBCT for PTSD consists of fifteen 75
min sessions comprised of three phases: (1) treatment and
education about PTSD and its impact on relationships and
increasing safety, (2) communication-skills training and
dyad-oriented in vivo exposures to overcome behavioral
and experiential avoidance, and (3) cognitive interventions
aimed at changing problematic trauma appraisals and
beliefs most relevant to the maintenance of PTSD and rela-
tionship problems (i.e., trust, power/control, and emotional
and physical closeness). Three uncontrolled studies with
Vietnam Veterans (Monson et al. [10]), Iraq and Afghani-
stan Veterans (Schumm et al.*), and community members
(Monson et al. [32]) and their romantic partners indicate
improvements in PTSD symptoms and their comorbidities
and some evidence of relationship improvements in couples
who may or may not be clinically distressed at the outset of
therapy (this is not an inclusion criteria for the therapy).
A wait-list controlled trial of CBCT for PTSD is
nearly complete. This trial includes a sample of individuals
with a range of traumatic events, including combat trauma,
and different types of intimate couples (i.e., married,
cohabitating, noncohabitating, same sex). The most recent
results from this trial indicate significant improvements in
PTSD and comorbid symptoms from pre- to posttreatment
that are maintained at 3 mo follow-up. These improve-
ments are on par with or slightly better than those found
with individual treatments. Additional benefits of the
therapy are significant improvements in relationship satis-
faction (e.g., Monson [33]). CBCT for PTSD is undergo-
ing initial testing for a range of CSOs and delivery in
multi-CSO groups.
DISCUSSION
Some evidence exists that educational groups are

associated with family members’ greater knowledge
about Veterans’ mental health symptoms, VA resources,
and decreased caregiver burden. There is not yet pub-
lished research on interventions designed to incorporate
CSOs to enhance engagement and retention in PTSD
assessment and treatment. As expected given the target of
the intervention, two RCTs of generic BCT or BFT with
Veterans and their families have yielded improved rela-
tionship functioning, but provide variable evidence
regarding significant improvements in PTSD symptoms.
A partner-assisted BCT provides evidence for improve-
ments in some symptoms of PTSD, but no evidence yet
establishes its efficacy for improving relationship satis-
faction. With regard to disorder-specific couple therapy,
some data support the efficacy of EFCT for Trauma in
couples, including a female partner with a history of
childhood sexual abuse; no group-level data for Veterans
with PTSD are available yet. Three uncontrolled trials
and results from an ongoing RCT of CBCT for PTSD
indicate that this therapy ameliorates PTSD symptoms,
enhances intimate relationship satisfaction, and improves
partners’ individual mental health and well-being.
CONCLUSIONS AND FUTURE DIRECTIONS
Our most recent military engagements have been met
with greater understanding of the multiple effects of PTSD
on the individual and the Veteran’s larger family unit.
Appreciating the toll that PTSD and its comorbidities can
have on family functioning, the VA was provided authority
by Public Law 110–387, “Veterans’ Mental Health and
Other Care Improvement Act,” in 2008 to include mar-
riage and family counseling as a service for family mem-
bers of all Veterans eligible for care. As a result, clinicians
with expertise in couple and family therapy have been

hired and training and dissemination efforts have been ini-
tiated to increase staff capacity to deliver evidence-based
couple/family interventions. This represents an important
step in providing Veterans and their family members with
access to a range of interventions to improve their indi-
vidual and relationship functioning.
We have presented a heuristic to help guide clinicians
in their PTSD treatment planning and provision. Although
there are no algorithms or empirically derived decision
trees to identify the treatment or treatment category most
appropriate for a given client, some general guidelines from
our own thinking and practices may be useful in treatment
planning. For example, if the Veteran has been unwilling to
engage in treatment and the goal is to engage the Veteran or
educate the CSO, the education/engagement interventions
*Schumm JA, Fredman SJ, Monson CM, Chard KM. Cognitive-
behavioral conjoint therapy for PTSD: Initial findings for
Operations
Enduring and Iraqi Freedom male combat veterans and their
part-
ners. Am J Fam Ther. 2012. In press.
725
may be most appropriate. In some situations, generic cou-
ple/family therapy may be the treatment of choice. If Veter-
ans with PTSD are engaged in trauma-focused treatment
for PTSD, do not wish for their CSO to be integrated into
that treatment, and they or their CSO are experiencing rela-
tionship distress, adjunctive generic couple/family therapy

may be included in the treatment plan. Decreasing ambient
stress caused by the Veteran’s distressed relationships and
enhancing social support may improve individual treatment
outcomes (e.g., Price et al. [34], Tarrier et al. [7]). Generic
couple/family therapy may also be pursued if the Veteran is
unwilling or not yet ready to engage in trauma-focused psy-
chotherapy for PTSD and is experiencing relationship dis-
tress. As reviewed, the skills taught in evidence-based
generic couple/family treatments (e.g., conflict manage-
ment, cognitive interventions) may have more diffuse
effects in improving PTSD and decreasing the stress on the
Veteran and CSO, thereby improving individual and rela-
tional functioning.
Partner-assisted interventions may be selected when
the Veteran is involved in individual therapy and the thera-
pist wishes to selectively include a supportive CSO to
maximize treatment delivery (e.g., facilitating in vivo expo-
sures to trauma-relevant cues). One cautionary note about
this method of CSO inclusion comes from the partner-
assisted agoraphobia treatment research [35]. We do not
recommend partner-assisted interventions in cases in which
the Veteran and CSO are experiencing relationship distress
because of the potential for increased conflict associated
with the CSO acting as surrogate therapist or coach.
Finally, in light of the accumulating evidence for the
efficacy of PTSD-specific couple/family interventions to
efficiently achieve multiple treatment outcomes, we rec-
ommend these treatments as a stand-alone option when-
ever a Veteran with PTSD and a partner are willing to
engage in them. Some may be inclined to present these
interventions when there is relationship distress. It is
important to note that the existing disorder-specific inter-
ventions for PTSD have been tested in a range of satisfied
couples (i.e., relationship distress has not been an inclu-

sion criteria), with partners diagnosed with multiple
comorbidities, to document benefits in individual and rela-
tional functioning. That said, if there is PTSD-maintaining
behavior within the relationship between the Veteran and
CSO (e.g., CSO accommodates avoidance behavior,
which serves to maintain PTSD symptoms) or relationship
distress, disorder-specific interventions may be especially
indicated. In addition to achieving multiple outcomes,
these treatments may confer additional service delivery.
For example, Veterans have reported that if not for their
CSOs’ involvement, they would not have engaged in
PTSD treatment. Again, these are recommendations based
on clinical experience and some data; further research
regarding these recommendations is needed.
The “family” portion of the “couple/family” label has
been relatively neglected in research on PTSD interven-
tions. More research is needed on interventions that apply
to broader family functioning and the effects of parental
mental health problems on children to better intervene at
the “family” level. In addition, while a significant propor-
tion of Veterans are married and have children, a sizable
minority are not in committed romantic relationships and
some are in committed same-sex relationships. We need
to consider inclusion of a broader range of Veterans’ close
others when striving to enhance engagement, assessment,
and treatment of PTSD.
Other important and growing demographic groups to
consider in couple/family treatment for PTSD are female
Veterans, aging Veterans who may present for the first time
with PTSD or have changes in their PTSD presentation, and
recently returning Veterans. Most of the research to date on
Veterans and couple/family treatments for PTSD has investi-
gated male Veterans with PTSD and their female partners.

Research on Vietnam Veterans and the most recent cohort of
Veterans suggests that female Veterans also have a myr-
iad of family problems and, in fact, may be especially at risk
for relationship problems and divorce (e.g., Gold et al. [36],
Karney and Crown [37]). Furthermore, the developmental
transition of retirement has been linked with relationship
distress, as well as the appearance of PTSD symptoms [38].
Retirement is also a time when other age-related physical
conditions and their treatment may increase relationship dis-
tress or exacerbate PTSD symptoms (e.g., cardiovascular
incidents, cognitive changes). Finally, returning Veterans of
recent conflicts are in great need of effective interventions
that address interpersonal conflict in order to prevent further
deterioration of relationships and development of chronic
PTSD. Research already has documented rising reports of
interpersonal relationship distress among these Veterans
[39] and their expressed interest in greater family
involvement in PTSD treatment (e.g., Batten et al. [3]).
Questions also remain regarding the most effective
aspects of the interventions we have reviewed. As the
field identifies efficacious treatments, future dismantling
studies may provide evidence about the essential compo-
nents of these interventions. In addition, more research is
726
needed on the most optimal mode of delivery (e.g., con-
joint therapy delivered to individual dyads, in a group of
dyads, via telehealth methodologies, paired with indi-
vidual therapy).
We are delighted with the growing awareness and

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