Behavioral Family Therapy For Chronic Combat-Related PTSD
By Shirley M. Glynn Ph.D.
NCP Clinical Quarterly 7(2): Spring 1997
As reflected in the NVVRS findings, severe psychosocial dysfunction, including high rates of divorce, poor work histories, alcohol and substance abuse, and difficulties in social relationships, often accompany core chronic PTSD symptoms(1). Carroll, Rueger, Foy, and Donahoe (2) reported that help-seeking veterans with combat-related PTSD evidenced significantly more difficulty in self-disclosure and demonstrations of affection with their partners, greater physical aggression toward their partners, and worse global relationship adjustment when compared to help-seeking combat veterans without PTSD or help-seeking non-combat veterans. Similarly, Keane, Scott, Chavoya, Lamparski, and Fairbank (3) found that social support declined post-discharge for combat veterans with PTSD, but improved for both combat and non-combat veterans without PTSD.
As has been described by Motta (4), relatives of the veteran with PTSD also suffer. In a review of the clinical literature, Solomon (5) noted that the emotional numbing and constricted affect associated with PTSD interferes with successful marital relationships and parenting. Physical aggression toward spouses and offspring is not uncommon. Wives may be especially burdened by concurrently caring for their husbands while protecting themselves and their children from his hostility. In the NVVRS, spouses of veterans with PTSD also reported greater psychological distress and more marital problems and family violence than those without PTSD (6). A recent report by Beckham, Lytle, and Feldman (7) suggests that this burden in caregivers actually increases over time, even if the veterans are receiving treatment. In a more clinical vein, Figley (8,9) has written extensively on how a member with chronic combat-related PTSD (usually a father) has a profound impact on the developmental course of the family.
Rationale For Utilizing Behavioral Family Therapy
In view of the well-documented distress in both veterans with PTSD and their loved ones, it is somewhat surprising that there have been no published controlled trials of family intervention for combat-related PTSD. At the West Los Angeles VA Medical Center, we are completing a clinical investigation on the benefits of adding behavioral family therapy (BFT) to a course of individual exposure therapy for Vietnam veterans with chronic combat-related PTSD. BFT (10,11) utilizes a skills training approach to learning to manage a longstanding, severe psychiatric disorder. Participation in BFT has been found to reduce relapse rates, compared to customary care, in a number of published investigations on schizophrenia (12-14); results on tests with other disorders are still pending. The availability of a manualized family-based treatment which has successfully reduced symptoms in other chronic psychiatric disorders and that could be adapted for PTSD prompted us to select it as an intervention to evaluate (11). Summarized over the past five years, our results indicate that veterans who participate in BFT after individual directed therapeutic exposure demonstrate approximately twice the reduction of PTSD reexperiencing and hyperarousal symptoms, compared to those participating in exposure alone.
A Description Of The Intervention
BFT is conducted with the patient and at least one other relative, who agrees to attend regularly. Most veterans identify a spouse or person with whom they co-habit as their primary relative. The veteran is encouraged to invite all family members over age 12 with whom he/she lives as well as any other relatives with whom he/she has significant ongoing contact; follow-up invitations may be extended by the therapist as well. Some issues, such as marital or sexual difficulties are best discussed with a subset of family members (e.g., the couple). In such a case, after the formal communication and problem-solving skills training has been completed, the later sessions can be devoted to these problems and are attended only by that family subset.
In our program(15), 16-18 one hour conjoint outpatient BFT sessions are conducted using a declining contact schedule (12-13 weekly meetings followed by 2-3 biweekly and then 2 monthly).
BFT is conducted in five stages, which are described below. While stages I-IV are considered important, developing a high level of problem-solving skill (stage V) to apply to extra-therapeutic settings is the ultimate BFT goal.
(I) Orientation and Assessment (3 sessions)
In a family session, the goals and expectations of both the therapist and the family are discussed. In addition, individual functional analyses are conducted with each participant separately to identify his/her assets, deficits, and current problems as well as to identify and behaviorally operationalize one or two relevant goals towards which the participant would like to work during the treatment.
An additional task for this stage involves clarifying how much information the veteran wishes to divulge about his/her experiences in Vietnam to his/her relative. It is critical that the therapist and veteran come to an explicit understanding about what the veteran wishes to reveal, and whether he/she would like any prompting in the family sessions to do so. In this endeavor, the therapist's responsibility is to aid the veteran in anticipating his/her relative's likely response to any disturbing Vietnam incidents and to evaluate whether revealing these incidents will have positive or negative effects.
(II) Education (2 sessions)
The goals of this phase of BFT include a) legitimizing the disorder, b) aiding the veteran and his/her family in developing realistic expectations for his/her functioning, and c) helping the veteran and his/her family become more informed consumers of and advocates for services. Basic information about the etiology, prevalence, symptoms, and treatment of PTSD is presented to the veteran and family. As is typical in BFT, the patient is deemed an "expert" on PTSD and is encouraged to discuss his/her symptoms and current experiences related to PTSD.
(III) Communication Training (3 sessions)
The aim here is to encourage the family to convene regular family meetings to discuss problems and goals in a frank and open manner. Training involves developing constructive expression of feelings and attitudes as well as empathic listening skills. A basic skills training format including repeated brief rehearsal, with coaching, modeling, out-of session practice assignments, and specific feedback and reinforcement is employed.
(IV) Anger Management (2 sessions)
Veterans and their families are first provided with training in expressing anger, frustration, and disappointment in a direct, constructive manner (i.e. being brief and specific, using "I" statements", etc.), followed by instruction in compromise and negotiation. While these skills are helpful, most families benefit from additional training on de-escalating situations which might lead to angry or violent outbursts. Topics addressed here include contracting for no violence among family members, identifying early signs of intense provocation, requesting a time-out when these cues occur, and understanding the role substance abuse plays in heightening conflict.
(V) Problem-solving Training (6-8 sessions)
This aspect of the family therapy model teaches the family to apply efficient problem-solving strategies to intra- and extra- familial stressors. Training employs behavioral rehearsal techniques, with family members conducting structured problem solving of current difficulties during the sessions under the tutelage of the therapist. Topics for problem-solving are defined by the family and may include issues related to any family member, not merely those associated with the veteran.
The crucial part of training is empowering families to employ effective problem-solving when handling stressors in the absence of the therapist. Between sessions, families are instructed to hold regular, identical "executive sessions" to deal with stressors that arise. Records of these are detailed on homework sheets which are discussed at the beginning of the following session. In addition to handling stressors, the problem-solving approach is applied to attainment of functional goals of all family members. Enhanced interpersonal, social, leisure and work functions (e.g., parenting, hobbies, jobs) are all legitimate topics for problem-solving discussions. The emphasis in problem-solving is the effective implementation of constructive strategies in a specific manner.
Adapting BFT To The Needs Of Veterans And Their Partners
We chose to test BFT, in part, because it had many elements that appeared especially relevant to veterans with combat-related PTSD and their partners, while being common to many effective behavioral marital interventions, such as those developed by O'Leary and Beach (16) for depression and O'Farrell, Cutter, and Floyd (17) for alcoholism. These included a) education focusing on legitimizing the disorder and supporting treatment compliance, b) training in problem-solving skills, which have been found to be deficient in veterans with combat-related PTSD (18,19), c) instruction in compromise and negotiation, anger management, and ways to deal appropriately with negative feelings, and d) a clear, well-articulated structure for both the therapist and couple with modest expectations for change.
However, our experience suggests that many features of chronic combat-related PTSD merit tailoring BFT to more closely fit the needs of veterans and their partners. We have been piloting the following modifications. We recommend that others providing treatment to this population consider implementing them, should they decide to utilize BFT.
First, living with chronic combat-related PTSD requires acceptance and tolerance on the part of both the veteran and his partner. Changes in symptomatic behavior are likely to be modest, and much of the work for the couple involves accommodating reduced expectations. In dealing with these issues therapeutically, the recent work by Jacobson and Christensen (20) can be useful. These authors highlight the importance of incorporating techniques to enhance partner acceptance and commitment to personal responsibility, rather then solely focusing on promoting behavior change, in behavioral marital therapy. This strategy seems to be especially relevant to chronic PTSD.
Second, we tailor assignments for increased out-of-session veteran and partner interaction to a very modest, tolerable level for the pair. For example, many family interventions include home-based "executive sessions" in which family members meet regularly for twenty to thirty minutes to discuss issues of importance to the family. Some veterans have found sitting with other family members during this meeting to be too anxiety-provoking, but they are often able to listen and participate while walking around the room or in a hallway nearby. Similarly, after years of avoidance, some couples find the prospect of spending a few hours together going to dinner and a movie as an assigned "date" as too intense. For these partners, the therapist can help shape the assignment to a more manageable task, such as the veteran hugging his wife or holding her hand at least once a day, or practicing his listening skills as his partner spends at least two minutes talking about the day's experiences.
Finally, communication skills training techniques which rest on persons being able to label and state their feelings accurately are not simple tasks for persons with PTSD (21). Remedial work is usually required, in which family members (including the veteran) are provided with comprehensive lists of feelings, and are encouraged repeatedly to consider carefully their choice of words in labeling an emotion when engaged in a communication task. The therapist must be prepared with visual prompts (e.g. easily accessible lists of feelings) and to allocate extra session time to permit exploration of feelings when veterans report they feel "numb" or "nothing". Further, in light of the prevalence of anger as the "acceptable" affect for veterans, the therapist must be especially adept at helping the veteran identify other potential emotions associated with the anger--shame, hurt, sadness, humiliation--and to model for the other partner how to remain calm and assist the veteran in clarifying complicated affects.
Summary
The results of research conducted with veterans with combat-related PTSD indicate that they frequently experience severe family dysfunction. Living with a veteran with PTSD is often stressful to spouses, children, and relatives and veterans and family members alike may benefit from family therapy. We have found that within the context of comprehensive PTSD treatment, an applied modification of BFT can effectively address the difficulties plaguing veterans and their families through family education, communication training, anger management, and problem-solving training.
References
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3. Keane, T. M., Scott, W. O., Chavoya, G. A., Lamparski, D. M., & Fairbank, J. A. (1985). Social support in Vietnam veterans with Posttraumatic Stress Disorder: A comparative analysis. Journal of Consulting and Clinical Psychology, 53, 95-102.
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15. Glynn, S. M., Eth, S., Randolph, E. T., Foy, D. W., Leong, G. B., Paz, G. G., Salk, J. D., Firman, G., & Katzman, J. W. (1995). Behavioral family therapy for Vietnam combat veterans with Posttraumatic Stress Disorder. The Journal of Psychotherapy Practice and Research, 4, 214-223.
16. O'Leary, K. D. & Beach, S. R. H. (1990). Marital therapy: A viable treatment for depression and marital discord. American Journal of Psychiatry, 147, 183-186.
17. O'Farrell, T. J., Cutter, H. S. G., & Floyd, F. J. (1985). Evaluating behavioral marital therapy for male alcoholics: Effects on marital adjustment and communication from before and after treatment. Behavior Therapy, 16, 147-167.
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20. Jacobson, N. & Christensen, A. (1996). Integrative couple therapy: Promoting acceptance and change. New York: W.W. Norton.
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Shirley M. Glynn received her Ph.D. in clinical/social psychology from the University of Illinois at Chicago. She is currently a Clinical Research Psychologist at the West Los Angeles VA Medical Center and an assistant research psycholgist in the Department of Psychiatry and Biobehavioral Science at UCLA. Dr. Glynn's primary professional activities involve conducting controlled trials of psychosocial interventions for serious psychiatric disorders, including schizophrenia and chronic PTSD. She is currently one of the clinical supervisiors for VA Cooperative Study #420 "Group Treatment for PTSD".
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