BETHESDA, MD—Identifying and describing how deployment and its effects can place stress on families is important, but it is only the first step in the healing process, researchers agreed at last month’s Trauma Spectrum Disorder Conference hosted here by NIH, VA and DoD. If researchers can describe and understand the damage being done to a family, then logic suggests there must be treatments that can be prescribed to heal that damage, or ways to strengthen families to help prevent damage from occurring in the first place.

While methods of helping military families cope with deployment stress is still more art than science, there are several avenues that are being examined and proving successful.

Teaching Resiliency

The optimal structure of multiple deployments is for a servicemember to have enough time between deployments to decompress, settle back into the family routine, and become comfortable with that routine again in order to enjoy it before needing to rev back up for redeployment. However, with the current operational tempo, downtime is not a time for relaxation, but a time for stress and worry about the impending next deployment.

“We know that the couples and the families are getting pretty ragged with these multiple deployments as they are gone for a cumulative amount of time,” explained William Saltzman, PhD, associate director of the FOCUS Project—a military family resiliency training system based out of UCLA. It is especially difficult for children and teens to re-engage with a parent who is gone for 4 out of 6 months of the year.

In 2007, the Defense Health Board Task Force on Mental Health identified a critical need for prevention and intervention services to foster resiliency within military families. FOCUS, Saltzman explained, emerged from that need. “Our approach is preventive. It’s resilience-enhancement. It’s not therapy,” he declared. “It’s a skill-based approach that makes it easier to get through some of the hurdles that might make it difficult form military families to seek services.”

In creating the program, physicians hypothesized certain sources of resilience in married couples. The first is knowledge about the biology of trauma and having an accurate expectation of what comes with deployment, operational stress, and, in the case of wounded servicemembers, with injury. Couples also need proper expectations of what is involved in children’s’ adjustment to deployment or injury.

Another source of resilience is shared beliefs … a common platform or vantage point in order to make sense of their adversity, both past and present. “It’s useful in a military situation is to help develop a sense of mission or a team approach to help them get together,” Saltzman explained. “It’s important, also, that they don’t minimize or overlook their strength and successes. It’s important to the sense of optimism. If spirituality is a resource in the family, we try to work with that.”

There is also a need for structure and flexibility. Both members of the relationship should have a clear expectation of their role, but also the ability to adapt if need be. And there needs to be honest communication, Saltzman said. “Our centerpiece work is in terms of communication. Military families might get soloed up so as not to burden each other. We want to foster a culture of openness in the family [and] an appreciation of the differences between husband and wife in terms of what the deployment experience has been like for them. There are different stressors, different interpretations, and different difficulties. Couples need to develop an accurate way of supporting each other and understanding what the other person needs.”

There is also a set of core relational skills that are important to families, including emotional regulation, goal setting, and problem solving. “Couples need to be cognizant and aware of trigger situations, situations that cause a person stress or to respond in an inappropriate way,” Saltzman explained. “Often these can become skills necessary for circuit-breaking or de-escalation, which can be really important.”

The FOCUS training program invites servicemembers and their family to seek treatment together. Initial sessions focus on preparing family members to identify and share their concerns and to understand family members’deployment reactions.These first sessions will frontload education about trauma and about deployment.

Later, in separate sessions with parents and children, family members will be taught emotional regulation, problem solving, goal setting, and communication skills. One important tactic to help family members understand each other is to create a narrative timeline of the deployment that is shared with the whole family in later sessions, Saltzman said. “It allows them to see what each person is doing and when they are under more stress, for both servicemember and family. Sharing of those narratives is a key way to accomplish some of these goals.”

Such sharing allows families to share each other’s perspective, clarifies confusion and misunderstandings, and encourages empathy. The end goal is that the family emerges from the training sessions with a better understanding of each other’s experiences, and with the tools to help them to better deal with deployment and reintegration.

The REACH Project

When a servicemember returns home wounded, either physically or emotionally, the reintegration process is made exponentially more complex, especially when that wound is an invisible one. One of the frequently uttered comments of the spouse of a service-member suffering from PTSD is that he or she is not the same person that left. Of veterans participating in a VA/PTSD outpatient program, 86% say PTSD is a source of family stress and 79% express interest in greater family involvement in VA outpatient treatment.

It was with this in mind that clinician-researchers at the Oklahoma City VAMC initiated the REACH (Reaching Out to Educate and Assist Caring, Healthy Families) Project. A psycho education model based on techniques proven to work with patients suffering from schizophrenia. REACH is designed to not only help couples understand what PTSD is and how it affects relationships, but also gives them tools to deal with it.

“We selected a multifamily model of psychoeducation (FPE), which was [originally designed for us with patients suffering from] schizophrenia and psychotic disorders with the goal of equipping consumers’ families with skills known to reduce relapse and promote quality of life,” explained Michelle Sherman, PhD, director of the family mental health program at the Oklahoma City VAMC.

Beginning in 2005, Dr Sherman and her colleagues began modifying the FPE treatment for PTSD and the VA. “We started with focus groups, some with veterans and some with families,” she said. “The veterans wanted more family involvement and the family members wanted to be more involved.”

Eligibility for the project is a primary diagnosis of PTSD, and patient proximity within 90 miles of the VAMC, since the program involves frequent therapy sessions. However, they opened the sessions up not only to spouses but also to any family member or friend of the servicemember that was willing to participate. “It could be a sibling, it could be your AA buddy,” Dr Sherman said. “It could even be an adult child.”

Between July 2006 and October 2009, Dr Sherman and her colleagues spoke with 378 veterans living with PTSD about the program, with 213 veteran/family groups having gone on to start the project. Most of those veterans were post-Vietnam-era and Persian Gulf-era veterans.

Phase one of the program includes four weekly 45-minute single-family sessions. The goal during these sessions is to build rapport, assess problems, assess social history and their existing network, and to enhance coping skills in preparation for phase two. Phase two involves six weekly 90-minute multi-family classes, with four to eight families in each class, and facilitated by a pair of psychologists. “The goal here is psychoeducation about PTSD and its impact on families,” Sherman explained. “We teach communication, problem solving, and coping skills [with a goal of] relationship enhancement.”

During these sessions, veterans split into one group and family and friends split into another. In these groups they talk about parallel topics and later come back and discuss what they talked about. Phase three of the program includes six monthly 90-minute multifamily group sessions, where veterans and their partners practice problem-solving scenarios.

The entire program lasts about nine months. Since its inception, 102 families (48% of participants) have gotten through all three phases. About 95% of REACH participants agreed to be evaluated to gauge the program’s success. Results showed a statistically significant increase in knowledge and understanding of PTSD for both veterans and their partners. There was also a significant increase in coping skills for both groups. Family members and friends also reported an increase in their sense of empowerment. Also, there was an improvement in interpersonal relationships.

“There was improvement in perceived social support and problem solving,” explained Ellen Fischer, PhD, another of the project’s investigators. “For those veterans who came in with distressed relationships at baseline, there were significant increases in relationship satisfaction over time.”

Investigators also saw an improvement in the veterans’ global symptom severity and in their depression, which was very encouraging considering the patient cohort were longtime sufferers of PTSD,” Dr Fischer declared. “REACH is a feasible, well-received family intervention for combat trauma.”

Investigators are currently speaking with OEF/OIF veterans and families to see what modifications can be made to the program to make it specifically attractive to them.

Conjoint Cognitive Behavioral Therapy

If PTSD causes disruptions in families, does improving PTSD automatically improve family functioning? The current research does not show this to be true, explained Candice Monson, PhD, and NIH-funded researcher at Ryerson University, Toronto, and former deputy director of VA’s National Center for PTSD.

Monson is currently examining the use of cognitive behavioral conjoint therapy for PTSD on servicemembers with PTSD and their spouses, with the understanding that, since PTSD is a disorder that heavily impacts those people nearest to the patient, they should be included in the therapy.

“PTSD is highly associated with relationship problems,” Monson explained. It’s one of the disorders that’s most robustly related to divorce and most robustly related to relationship problems when those couples stay together. And a negative family environment is associated with worse outcome in individual treatment. Even if you are sending this person out into the world after receiving individual treatment, if they are going home to a hostile, negative environment, they don’t benefit from the treatment as much as those with a healthy home environment.”

The commonly used existing therapies are not designed to improve intimate relationship problems, she added. Any intervention targeted at helping a family cope with PTSD needs to be explicitly developed to improve intimate relationship functioning as well as focus on the mechanisms that are driving the disorder.

The therapy Dr Monson is currently testing is focused on just that—tackling the disease and the ways it disrupts relationships. “It’s trauma-focused,” she explained, “but it’s not imaginal exposure-based. This is not a therapy developed to go over the trauma again and again. The interventions we use here to focus on the trauma are cognitive in nature. We are asking the couple to make sense of what happened to the individual. We’re looking at the 30,000-foot view, not the nitty-gritty view.”

Monson’s treatment includes 15 sessions of an hour and a half each and plays out in three stages. “The first stage consists of two sessions that are about psychoeducation: Why is this therapy going to work, how do you understand the inclusion of a loved one in therapy, and conflict containment skills?”

The second stage is based on traditional cognitive behavioral therapy principles and focuses on relationship enhancement skills and typical communication skills training. “We put a particular focus on undermining avoidance, which is a major factor in PTSD and an important part of what erodes relationship quality,” Dr Monson explained. “We want to get the couple back into life … the life they would have if they were a satisfied couple.

Stage three deals with dyadic cognitive restructuring. “It’s a process where they come together and they have a reality test. In good relationships, we bounce ideas off of our loved ones: How do I make sense of the here and now, and how do I make sense of the past and what has happened to me?”

The pilot study funded by NIH is complete, with no dropouts. Results of the pilot showed a significant decrease in PTSD symptom severity, with a 75% drop in avoidance, as well as major improvements in relationship satisfaction. “There were no improvements in depression in the partners, but there were improvements in comorbid depression in the individual with PTSD,” Monson noted. DoD is currently funding a head-to-head trial of the intervention compared to prolonged exposure therapy in active-duty servicemembers.

And there are other questions that still need answers. For example, are all three stages of the treatment necessary? Returning veterans want the quickest treatment possible, and Monson is examining whether the third stage is necessary if veterans see improvement after stages one and two. Also, do couples that have high relationship satisfaction coming into the treatment do better or worse?

Monson also suggested that, in the future, researchers need to be thinking about dually traumatized couples, where both people in the relationship have PTSD. “People who have problems tend to find people who have problems.

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