Can families help veterans get more from PTSD treatment? A randomized clinical trial examining Prolonged Exposure with and without family involvement

Meis, Laura; Glynn, Shirley M.; Spoont, Michele; Kehle‐Forbes, Shannon M.; Nelson, David B.; Isenhart, Carl E.; Eftekhari, Afsoon; Linden, Erin B; Orazem, Robert J.; Cutting, Andrea; Campbell, Emily M Hagel; Astin, Millie C.; Porter, Katherine E.; Smith, Erin R.; Chuick, Christopher D; Lamp, Kristen; Vuper, Tessa C.; Oakley, Taylor A; Khan, Lila B; Keckeisen, Sally K; Polusny, Melissa A.

doi:10.1186/s13063-022-06183-2

Cited by 12 publications

(8 citation statements)

References 64 publications

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“…The potential for CBCT to increase adequate engagement in PE or CPT is important because retention in outpatient PTSD treatment is low and treatment retention in an individual course of therapy for PTSD is much more likely to result in a significant reduction in PTSD symptoms . Our findings are consistent with preliminary research that suggests that brief family involvement (ie, 2 sessions of psychoeducation and skill building) in the veteran’s individual treatment of PTSD can improve treatment retention in individual therapy .…”

Section: Discussionsupporting

confidence: 79%

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Retention in Individual Trauma-Focused Treatment Following Family-Based Treatment Among US Veterans

Dodge,

Sullivan,

Grau

et al. 2023

JAMA Netw Open

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ImportanceDespite the availability of several empirically supported trauma-focused interventions, retention in posttraumatic stress disorder (PTSD) psychotherapy is poor. Preliminary efficacy data shows that brief, family-based interventions may improve treatment retention in a veteran’s individual PTSD treatment, although whether this occurs in routine clinical practice is not established.ObjectiveTo characterize receipt of family therapy among veterans diagnosed with PTSD and evaluate whether participation in family therapy is associated with an increased likelihood of completing individual trauma-focused treatment.Design, Setting, and ParticipantsThis retrospective cohort study used the Veterans Health Administration (VHA) Informatics and Computing Infrastructure to extract electronic health record data of participants. All participants were US veterans diagnosed with PTSD between October 1, 2015, and December 31, 2019, who attended at least 1 individual trauma-focused treatment session. Statistical analysis was performed from May to August 2023.ExposuresReceipt of any family psychotherapy and subtype of family-based psychotherapy.Main Outcomes and MeasuresMinimally adequate individual trauma-focused treatment completion (ie, 8 or more sessions of trauma-focused treatment in a 6-month period).ResultsAmong a total of 1 516 887 US veterans with VHA patient data included in the study, 58 653 (3.9%) received any family therapy; 334 645 (23.5%) were Black, 1 006 168 (70.5%) were White, and 86 176 (6.0%) were other race; 1 322 592 (87.2%) were male; 1 201 902 (79.9%) lived in urban areas; and the mean (SD) age at first individual psychotherapy appointment was 52.7 (15.9) years. Among the 58 653 veterans (3.9%) who received any family therapy, 36 913 (62.9%) received undefined family therapy only, 15 528 (26.5%) received trauma-informed cognitive-behavioral conjoint therapy (CBCT) only, 5210 (8.9%) received integrative behavioral couples therapy (IBCT) only, and 282 (0.5%) received behavioral family therapy (BFT) only. Compared with receiving no family therapy, the odds of completing individual PTSD treatment were 7% higher for veterans who also received CBCT (OR, 1.07 [95% CI, 1.01-1.13]) and 68% higher for veterans received undefined family therapy (OR, 1.68 [95% CI, 1.63-1.74]). However, compared with receiving no family therapy care, veterans had 26% lower odds of completing individual PTSD treatment if they were also receiving IBCT (OR, 0.74 [95% CI, 0.66-0.82]).Conclusions and RelevanceIn this cohort study of US veterans, family-based psychotherapies were found to differ substantially in their associations with individual PTSD psychotherapy retention. These findings highlight potential benefits of concurrently providing family-based therapy with individual PTSD treatment but also the need for careful clinical attention to the balance between family-based therapies and individual PTSD treatment.

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Section: Discussionsupporting

confidence: 79%

“…31,32 Our findings are consistent with preliminary research that suggests that brief family involvement (ie, 2 sessions of psychoeducation and skill building) in the veteran's individual treatment of PTSD canJAMA Network Open | Psychiatry…”

supporting

confidence: 84%

Retention in Individual Trauma-Focused Treatment Following Family-Based Treatment Among US Veterans

Dodge,

Sullivan,

Grau

et al. 2023

JAMA Netw Open

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“…In this small RCT (N = 20 dyads), veterans in this condition were less likely to drop out of treatment than those in standard CPT or PE alone. Additionally, Meis et al (2022) designed an RCT to compare standard PE to family-supported PE, in which an SP attends the first three sessions and joins sessions later in treatment to check-in. The goal of the SP's inclusion is to collaboratively identify ways for the SP-veteran dyad to work together to help the veteran get the most out of PE.…”

Section: Discussionmentioning

confidence: 99%

The role of symptom accommodation in trauma‐focused treatment engagement and response

Howard

Spoont

Polusny

et al. 2023

Journal of Traumatic Stress

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Although trauma‐focused treatments (TFTs) are generally effective, not all patients improve. Symptom accommodation (i.e., altering one's behavior in response to another's symptoms) by loved ones may be particularly relevant to TFT treatment response and engagement. We examined the role of symptom accommodation by support persons (SPs) in veterans’ PTSD treatment response, including the mediating role of treatment engagement and the moderating role of relationship strain. Veterans engaging in prolonged exposure or cognitive processing therapy and a loved one (N = 172 dyads) were sampled at two time points approximately four months apart. Measures of treatment engagement (i.e., highest session completed from the treatment protocol and homework completion) were obtained from hospital records. We found that relationship strain moderated the effect of symptom accommodation on treatment response, ∆R2 = .02. Specifically, Time 1 (T1) accommodation predicted poorer treatment response (i.e., Time 2 [T2] PTSD symptom severity, controlling for T1 symptoms) among veterans who reported below‐average relationship strain only. Additionally, symptom accommodation was indirectly related to treatment response such that T1 accommodation predicted higher T2 PTSD symptom severity specifically through reduced homework completion, β = .01. The findings suggest that attending to accommodating behaviors of veterans’ supportive partners may be an important way to boost both engagement in and response to TFTs for PTSD.

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“…For example, couples-based, trauma-informed therapies are associated with robust improvements in PTSD symptoms, while also enhancing relationship satisfaction (Macdonald et al, 2016; Monson et al, 2012). Yet only in the last few years have family-based approaches been leveraged to increase engagement in PTSD therapy generally or evidenced-based PTSD psychotherapies (EBPs), specifically prolonged exposure and cognitive processing therapy (Meis et al, 2022; Shepherd-Banigan et al, 2022; Thompson-Hollands, Lee, & Sloan, 2021). Limited engagement in PTSD therapy is a major barrier to promoting recovery for veterans with PTSD at a population level.…”

Section: The Present Studymentioning

confidence: 99%

Mental health therapy for veterans with PTSD as a family affair: A qualitative inquiry into how family support and social norms influence veteran engagement in care.

Shepherd‐Banigan

Shapiro

Sheahan

et al. 2023

Psychological Services

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Social support is important for posttraumatic stress disorder (PTSD) recovery and emerging literature indicate that social support could increase engagement in PTSD therapy. However, there is a need to understand how and why family involvement can increase treatment engagement to inform strategies used in clinical practice. This study explores how individuals with PTSD and family members of individuals with PTSD experience therapy and how social interactions help or hinder therapy engagement. We interviewed 18 U.S. military veterans who had been referred for psychotherapy for PTSD in the Veterans Health Administration and 13 family members and used rapid content analysis to identify themes. We found that engaging in therapy was a family-level decision that participants expected to improve family life. Veterans were motivated to seek treatment to protect their relationships with loved ones. Family members generally encouraged veterans to seek treatment. Specifically, family members who viewed PTSD as a treatable illness versus a static aspect of the veteran's personality expressed positive attitudes about the effectiveness of therapy for reducing symptoms. Veterans whose social networks included individuals with prior military or trauma-related experiences reported that their loved ones possessed more understanding of PTSD and described positive subjective norms around therapy. Family members are often embedded in the therapy process because PTSD has a profound impact on the family. Positive subjective norms for therapy are created by family encouragement and may influence veteran perceptions about the value of treatment. Family members should

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Can families help veterans get more from PTSD treatment? A randomized clinical trial examining Prolonged Exposure with and without family involvement

Cited by 12 publications

References 64 publications

Retention in Individual Trauma-Focused Treatment Following Family-Based Treatment Among US Veterans

Retention in Individual Trauma-Focused Treatment Following Family-Based Treatment Among US Veterans

The role of symptom accommodation in trauma‐focused treatment engagement and response

Mental health therapy for veterans with PTSD as a family affair: A qualitative inquiry into how family support and social norms influence veteran engagement in care.

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