Couple/family Therapy for Posttraumatic Stress Disorder: Review to Facilitate Interpretation of VA/DOD Clinical Practice Guideline

Article excerpt

INTRODUCTION

To their credit and our benefit, Veterans and their families have been the predominant contributors to our knowledge 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., 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 provides 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 Practice 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 interventions for PTSD using Psychlnfo, MEDLINE, ERIC (Education Resources Information Center), and Google-Scholar databases. The following search terms were used: couple therapy, conjoint therapy, family therapy, interpersonal, PTSD, and trauma.

RESULTS

VA/DOD Clinical Practice Guideline Regarding 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 intervention. 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 psychotherapies" [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 recommend for or against Family or Couples Therapy as a firstline 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" rating and subratings of level and strength of evidence, we disagree with the conclusion drawn from the studies reviewed. …