Running head ARTICLE REVIEW .docx

Article Review
1. Article # - (just the number identifying your article, e.g. 1,
2, 3, etc.)
Article 1: Lee, C. Y., Furnham, A., & Merritt, C. (2017). Effect
of the directness of the exposure and trauma type on Mental
Health Literacy of PTSD. Journal of mental health, 26(3), 257-
263.
2. What is the article about?
Lee, Furnham and Merritt sampled 233 participants and
allocated to the participants to one of the six vignettes including
direct or indirect exposure to military combat rape, and human-
made disaster to establish the effect of directness exposure to
traumatic events on PTSD’s Mental Health Literacy.
3. What was the purpose of this research?
This study’s purpose was to establish how direct or indirect
exposure to traumatic events affects PTSD recognition. The
research aimed at establishing how PTSD recognition varies in
the three traumatic events, including military, rape, and human-
made disasters. The authors hypothesized higher PTSD
recognition in direct as compared to direct exposure to
traumatic events, and the rate of recognition varies with the
traumatic event.
4. Findings/results of the study?
The results of the result indicated a higher rate of PTSD
recognition in direct exposure as compared to indirect exposure
to trauma. As well, the rate of PTSD recognition varies with
traumatic events, higher in the military and human-made
disaster events and lower in rape cases. The rate of recognizing
PTSD was below 50 percent, indicating lower PTSD

understanding in the general public. As well, the low rate of
PTSD recognition in indirect exposure to traumatic events
indicates unawareness that indirect exposure to trauma leads to
PTSD.
5. Any acknowledged strengths and weaknesses of the study?
The study did not acknowledge the study strengths but indicated
some limitations. The small sample size is one of the study’s
weakness, and the participants comprised of students and
younger adults limiting the generalizability of the study
findings to middle and older adult populations. As well, the
study examined only three traumatic events, yet many traumatic
events lead to PTSD.
6. Implications for practice, i.e. how will the results be used
and knowledge applied?
The low rate of PTSD recognition in the study presents a need
to raise awareness and increase education regarding PTSD, in
particular, PTSD resulting from indirect exposure to traumatic
events.
7. Keywords
Post-Traumatic Stress Disorder (PTSD), Mental Health
Literacy, trauma, indirect exposure

Article Review
1. Article # - (just the number identifying your article, e.g. 1, 2,
3, etc.)
Article 2: Ló.pez‐Zerón, G., & Blow, A. (2017). The role of
relationships and families in healing from trauma. Journal of
Family Therapy, 39(4), 580-597.
The authors of the article utilize a case study to demonstrate
systematic trauma approaches relevance and benefits.
Systematic approaches, in this case, addresses both
interpersonal difficulties and relationship difficulties among the
survivors.
The article summarizes individual, group, and relational
treatment interventions for trauma based on evidence and
presents the significance of family inclusion in trauma
treatment. The authors of the article challenge the systematic
intervention field to offer more research, which leads to
systematic approach becoming a major consideration in trauma
treatment among survivors and family members.
The article documents evidence supporting cognitive processing
therapy, exposure therapy, and eye movement desensitization
therapy as effective individual therapies addressing
interpersonal conflicts. As well, group therapy has been
documented to raise normalization and social support. Couple
and family therapy interventions including functional family
therapy and emotionally focused therapy have been indicated to
help in offering a supportive environment for the trauma
survivors by increasing positive support, the connection among
members of the family, reducing negative interactional cycles,
and creating safety. As well, relational interventions comprising
of psychoeducational elements and attention to a reconnection

and bonding process within the system enhance family
functioning, which is important to the treatment of trauma
survivors. The article acknowledges the lack of full integration
of systematic interventions in trauma treatment interventions
due to the lack of efforts to increase the scope of the research
indicating the effectiveness of these interventions.
The authors of the article do not present any study strengths and
weaknesses.
The article findings are important to increasing the use of the
systematic intervention in trauma treatment. The study has
indicated the effectiveness and benefits of systematic
interventions in treating trauma survivors and thus the need for
intensified advocacy efforts to increase their use and more
research to expound on understanding these interventions. As
well, more training is needed among therapist to enhance their
ability to use systematic approaches.
7. Keywords
Trauma; evidence-based practices
Article Review

3, etc.)
Article 3: MacKinnon, L. (2014). Deactivating the buttons:
Integrating radical exposure tapping with a family therapy
framework. Australian and New Zealand Journal of Family
Therapy, 35(3), 244-260.
The authors use cases to describe Radical Exposure Tapping.
The article begins by defining trauma, treatments that work for
PTSD, elaboration of the Eye Movement Desensitization and
Reprocessing, Emotional Freedom Technique, and Radical
Exposure Tapping. As well, the article documents integrating
radical exposure tapping with family therapy.
This article’s aim is to demonstrate Radical Exposure Tapping
and show it as an effective intervention which can be combined
with family therapy to treat the emotional reactivity of the
family effectively.
The article documents the shortcomings of the various available
treatments for PTSD in their integration with family therapy.
According to the authors, trauma-focused cognitive behavioral
therapy consumes time, emotional freedom technique lacks
theory and thoroughness, and eye movement desensitization and
reprocessing is inflexible. The study indicates that Radical
Exposure Tapping taps the emotional freedom technique
sequence and combines the methodology involved in eye
movement desensitization reprocessing. This makes Radical
exposure tapping more rigorous and flexible and effective
within the family therapy context to address the emotional
reactivity of the family members.
The authors of the article do not present the strengths and
limitations of the article.

The article’s findings are essential in trauma treatment in family
therapy. The article documents the effectiveness of radical
exposure tapping to address traumatic life events which emerge
in family therapy and thus important to therapists seeking to
address the emotional reactivity of the family members to
traumatic events.
7. Keywords
Trauma, Post-Traumatic Stress Disorder, Criterion A, emotional
reactivity, emotional trigger, Radical Exposure Tapping, Eye
Movement Desensitization and Reprocessing, Emotional
Freedom Technique, single session, brief intervention, family
therapy
Article Review
3, etc.)
Article 4: Saltzman, W. R. (2016). The FOCUS family
resilience program: An innovative family intervention for
trauma and loss. Family Process, 55(4), 647-659.

The article uses a case to demonstrate the FOCUS Program as
an innovative intervention geared towards enhancing the
resilience of families contending with various traumatic events
through hand-on activities which establish major stressors and
reinforces resilient processes. The article offers a description of
the FOCUS Program, including prompting family goals,
providing family psychoeducation, developing collective family
narrative, communication, and enhancing family resilience
skills.
The aim of this article is to document the primary philosophies
and elements of the FOCUS Program as a program centered on
family and strengths to flexibly tackle the needs of populations
struggling with various trauma experiences.
The article indicates that FOCUS Program offers a platform for
bringing families together, developing collective goals, and
working with children, fathers and mothers and the whole
family for building communication, making sense out of trauma
events, and practicing skills which reinforces the resilience of
the families. The article records the effectiveness of the FOCUS
Program in diminishing parental depression, anxiety, and
posttraumatic stress as well as child emotional and behavioral
difficulties. As well, the program enhances the overall family
functioning.
The author does not document the strengths and limitation of
the article.
The study results are important in behavioral healthcare entities.
Since participation in the FOCUS Program is associated with
diminished symptomatic behavior and distress for parents and
children and enhances family resilience and child pro-social
behaviors, behavioral healthcare entities should integrate

principles and elements in the FOCUS Program.
7. Keywords
Family Resilience; Family Therapy; Trauma; Loss; Narrative;
Medical Trauma
Article Review
3, etc.)
Article 5: Monson, C. M., Macdonald, A., & Brown-Bowers, A.
(2012). Couple/family therapy for posttraumatic stress disorder:
Review to facilitate interpretation of VA/DOD Clinical Practice
Guideline. Journal of Rehabilitation Research & Development,
49(5), 717-728
The authors of the article reviewed the couple and family
therapy recommendations in the newest Veteran Affairs/
Department of Defense clinical practice for PTSD management

to treat PTSD among in Veterans and Veterans’ families.
The research’s aim was to review couple and family therapy
recommendations made to the new version of VA/DOD clinical
practice guideline to manage PTSD and offer a heuristic for
behavioral health practitioners, researchers and policymakers to
take into account when integrating couple and family therapy
into the mental health services among Veterans and their
families.
The authors documented the efficacy of behavioral couple
therapy and behavioral family therapy in improving symptoms
of PTSD and relationship functioning among the Veterans. As
well, cognitive-behavioral conjoint therapy has been found to
improve the symptoms of PTSD, enhance the satisfaction of
intimate relationships, family functioning, and enhances
individual mental health and welfare of the Veterans together
with their partners and children.
The authors do not acknowledge the strengths and limitation of
this study.
The article has presented a heuristic to assist in guiding the
behavioral health practitioners in planning for PTSD treatment
and prevision. Since the study has documented the efficacy of
couple and family therapy in PTSD treatment and enhancing the
relationship and family functioning, VA/DOD mental health
services can incorporate these approaches to enhance the
wellbeing of the Veteran and their families.
7. Keywords
caregiver burden, clinical practice guidelines, cognitive-
behavioral therapy, couple/family therapy, emotionally focused
couple therapy, mental health, PTSD, rehabilitation, strategic
approach therapy, Veterans.

2
APPLYING THEORY
Running head: APPLYING THEORY
1
Applying Theory to Specific Settings and Populations
Applying Theory to Specific Settings and Populations
Employment is a concern that affects society,
communities, families, and individuals. The world of work has
changed considerably with each generation: advances in
technology, changes in jobs and industries, high unemployment,
universal health care, and lower wages, to name a few
(Shoffner, 2006). To meet the needs of our clients today,
counselors should be knowledgeable in career theories that can
be applied to their career choice and development. This paper
focuses on two theories: Social Cognitive Career Theory
(SCCT), and Theory of Work Adjustment (TWA). This author
identifies the strengths and weaknesses to both perspectives,
and explains how these theories may be applied to trauma and
crisis populations.
Work Setting and Client Population
For the last ten years I worked in the field of education as an
elementary school teacher. I recently made a career change that
I felt compelled to follow: to counsel victims of violence and
trauma survivors. I am currently not working in the field of

mental health; however, I wish to pursue any work setting such
as a hospital, shelter, or agency that serves victimized
populations. I also aspire to get involved with Red Cross or
FEMA relief agencies when services are needed for disaster
relief. I want to give back to the community, and make it count.
Social Cognitive Career Theory (SCCT) and Theory of Work
Adjustment
Social Cognitive Career Theory (SCCT) is a learning and
cognitive approach to career development and choice (Shoffner,
2006). The key concepts of self-efficacy beliefs, outcome
expectations, and career choice barriers and supports, contribute
to career interests, goals, and behavior (Morris, Shoffner, &
Newsome, 2009). Chronister & McWhirter (2003) assert that
SCCT integrates the role of environmental influences on the
“development and pursuit of vocational and educational
interests, choices, and performance” (p. 419). In short, people’s
interests and aspirations are influenced by their belief that they
can do things well.
The Theory of Work Adjustment (TWA), by Dawis,
England, and Lofquist, was developed from the trait and factor
approach to career counseling. TWA posits that success on the
job results from a good “fit” between individuals and their work
environments (Shoffner, 2006). The four main components of
TWA are satisfaction, person--environment correspondence,
reinforcement value, and ability, addressing both individual
characteristics and pertinent environmental factors (Shoffner,
2006).
Similarities and Differences
Social Cognitive Career Theory and Theory of Work
Adjustment both have a solid and extensive research base with
continuous empirical findings to support their theoretical
approaches to career development. Both theories may be applied
to a variety of populations such as “girls and women, members
of racial minority groups, and gay and lesbian individuals”
(Shoffner, 2006, p. 58).
Both theories support the influences of person and environment;

however SCCT focuses on overcoming perceived barriers and
challenges to career development, that impact one’s negative
view of self; while TWA focuses on a congruent match between
person (trait) and environment (factor) in obtaining job
satisfaction (Shoffner, 2006).
Strengths and Weaknesses
A weakness of TWA is the assumption that career decisions are
based mainly on measured abilities which restricts a range of
factors to be considered in the career development process. In
essence, “TWA is considered too narrow in scope” (Zunker,
2011).
Theories Applied to Trauma and Crisis Populations
Career decision making is a critical element of a successful
return to work for women trauma survivors (Gittens, 2011). To
ease the transition, counselors should assess and explore career
options of interest to their clients. A key factor in a successful
return to work is the fit between women survivors and their
work environments which takes place when “correspondence,
mutual responsiveness and satisfaction exist between the
individual and the work environment” (Gittens, 2011, p. 44).
The closer the match or “fit” between trait and environment, the
better likelihood of job success.
Women, who enter into counseling with negative beliefs and
thoughts about themselves, are underestimating their potential
for happiness, job satisfaction, and financial security. Women
encounter challenges and obstacles throughout their career
development process that influence their self-efficacy beliefs,
and goal setting (Coogan, & Chen, 2007). Barriers such as
discrimination, gender-role socialization, employment
inequities, and family responsibilities will deter women from
pursuing what they aspire to do and be, especially if they have
convinced themselves they are not good at or incapable of doing
something (Coogan, & Chen, 2007).

References
Coogan, P. A., & Chen, C. P. (2007). Career development and
counseling for women: Connecting theories to practice.
Counselling Psychology Quarterly, 20(2), 191-204.
Gittens, G. E. (2011). Women trauma survivors' experiences of
returning to work: an exploratory
study. Counseling Psychology Dissertations. Retrieved from
http://iris.lib.neu.edu/cgi/viewcontent.cgi?article=1019&context
...diss
Morris, C., Shoffner, M. F., & Newsome, D. W. (2009). Career
counseling for women preparing
to leave abusive relationships: A social cognitive career theory
approach. The Career
Development Quarterly, 58(1), 44-53.
Shoffner, M. F. (2006). Career counseling: Theoretical
perspectives. In D. Capuzzi & M. D.
Stauffer (Eds.), Career counseling: Foundations, perspectives,
and applications. (pp. 40-
68). Boston: Allyn and Bacon.
Zunker, V. G. (2011). Career counseling: A holistic approach.
Belmont: Thompson Learning,
Inc.
Running head: CAREER SELF ASSESSMENT 1
2
CAREER SELF ASSESSMENT

How to use a template week to week:
http://screencast.com/t/MX7rAtCqk0
How to fix your line spacing:
http://screencast.com/t/zeDQjm4m
Vocational/Career Self Assessment
Your Name
Walden University
Vocational/Career Self Assessment
Introduce your paper by saying something general about
the main topic (e.g., the purpose of self-assessment in career
development). Keep in mind that each section (under each
heading) will need at least one paragraph (i.e. a minimum of
three sentences). Title page and references do not count toward
page length, and you should write in first person and active
voice. In this paper, I will…..
Self-Assessment Results
In this paragraph, present a brief summary of your results
from the assessments you took. Briefly address the differences
between the SDS and the assessment you chose from the Walden
Career Center. Using multiple resources will support your
points further.
Self-Directed Search (SDS)
In this paragraph, present your reactions to your SDS
results. With that reaction in mind, discuss what type of support
or reaction you would want from a career counselor if they were
working with you on this tool. Be sure to support your points
with the learning resources. Using multiple resources will
support your points further.

SWOT – or – SkillScan – or - StrengthFinder
In this paragraph, present your reactions to the assessment
you chose after watching the Walden Career Center video. With
that reaction in mind, discuss what type of support or reaction
you would want from a career counselor if they were working
with you on this tool. Be sure to support your points with the
learning resources. Using multiple resources will support your
points further.
Reactions and Application
In this paragraph, discuss your overall insights from
completing this assignment. What did you learn about yourself?
What did you find most valuable about completing the self-
assessments and being introduced to the Walden Career Center?
In this paragraph, address future application of your awareness
of self-assessments. How do you think it might be for you to
work with a client who takes this assessment? What concerns do
you have about working with clients who choose self-
assessments?
All papers need a summary. Briefly remind the reader of what
you just covered. Start the paragraph with the following
sentence. In this paper, I addressed self-assessment in career
counseling and reviewed the results of my own self-assessment.
Then add 2 more sentences, and you’re done!
References
Laureate Education, Inc. (2007). Vocational psychology and
counseling. Baltimore, MD: Author.
Shen-Miller, D. S., McWhirter, E. H., & Bartone, A. S. (2012).
Historical influences on the evolution of vocational counseling.
In D. Capuzzi & M. D. Stauffer (Eds.), Career Counseling:
Foundations, perspectives, and applications (2nd ed., pp. 399-
428). Boston, MA: Pearson Education.
Week 2 Application Assignment Rubric

Criteria
1
Exemplary
2
Proficient
3
Progressing
4
Emerging
Score
Meets Assignment Objectives
Application: Applying Theory to Specific Settings and
Populations
· Briefly describe your work setting and client population.*
· Briefly summarize the two theories you have selected.
· Compare/Contrast them: Describe the similarities they share
and their major differences.
· Explain the strengths of these two theories as they relate to

your setting and client population.
· Describe the weaknesses you would have to address and,
briefly, how you would address them.
· Finally, briefly explain how you would apply these theories in
your practice.
Responsive to and exceeds the requirements
4 points
Responsive to and meets the requirements
3–3.5 points
Somewhat responsive to the requirements
2–2.5 points
Unresponsive to the requirements
0–1.5 points
/4
Application of Knowledge

Demonstrates an ability to think about, use, and integrate course
material.
In-depth understanding and application of concepts and issues
presented in the course (e.g., insightful interpretations or
analyses; accurate and perceptive parallels, ideas, opinions,
examples, and conclusions)
4 points
Basic understanding and application of the concepts and issues
presented in the course demonstrating that the student has
absorbed the general principles and ideas presented
3–3.5 points
Minimal understanding and little application of concepts and
issues presented in the course or, while generally accurate,
displays some omissions and/or errors
2–2.5 points
Lack of understanding and little or no application of the
concepts and issues presented in the course; and/or the
application is inaccurate and contains many omissions and/or
errors
0–1.5 points
/4
Writing
demonstrates graduate-level writing.
Application meets graduate-level writing expectations, uses

language that is clear and concise, has a few or no errors in
grammar or syntax, is well organized and clear, and adheres to
APA style with few or no mistakes
4 points
Application meets most graduate-level writing expectations,
uses language that is clear, has a few errors in grammar or
syntax, is well organized and clear, and adheres to APA style
with few mistakes
3–3.5 points
Application partially meets graduate-level writing expectations,
uses unclear and inappropriate language, has significant
grammar or syntax errors, lacks organization, OR demonstrates
significant issues with APA style.
2–2.5 points
Application does not meet graduate-level writing expectations,
uses unclear and inappropriate language, has significant
grammar or syntax errors, lacks organization, AND
demonstrates significant issues with APA style.
0–1.5 points
/4
12 points
100%

9–10.5 points
75–87.5%
6–7.5 points
50–62.5%
0–4.5 points
0–37.5%
Total Score
/12
© 2015 Laureate Education, Inc. Page 2 of 2
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
V
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-
ily functioning.
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.
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
ntly more
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
attention paid to the partners and family members who
surround Veterans with PTSD. We anticipate that the next
years will bring a number of important innovations in
basic research, prevention, and treatment related to the
families of Veterans with PTSD. These efforts will surely
inform the next revision of the VA/DOD CPG and, in the
meantime, hopefully our practices as clinicians, research-
ers, and policy makers to best serve Veterans with PTSD
and their loved ones.
ACKNOWLEDGMENTS
Author Contributions:

A. Brown-Bowers.
Acquisition of data: C. M. Monson, A. Macdonald, A. Brown-
Bowers.
Analysis and interpretation of data: C. M. Monson, A.
Macdonald,
A. Brown-Bowers.
A. Brown-Bowers.
Critical revision of manuscript for important intellectual
content:
C. M. Monson, A. Macdonald, A. Brown-Bowers.
Obtained funding: C. M. Monson.
Administrative, technical, or material support: C. M. Monson,
A. Macdonald, A. Brown-Bowers.
Study supervision: C. M. Monson.
Financial Interests: The authors have declared that no
competing
interests exist.
Funding/Support: This material was based on work supported in
part
by a grant from the National Institute of Mental Health (R34
MH076813).
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This content is in the Public Domain.
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,
Gabriela López-Zerón and Adrian Blow584
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

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