Goals for Training

1. Cognitive-Behavioral Conjoint Therapy for Combat Stress Reactions and Intimate Relationship Problems

2. Goals for Training

3. Sociocultural Factors Related to Recovery ethnicity Litigious/fault-finding dyadic adjustment appraisals hippocampus serotonin 5-HTTLPR social support intimacy experiential avoidance views on rape/incest stability of marriage/family Monson, Fredman & Dekel (in press)

4. Intimate Relationships and PTSD Community samples, comparing with couples in which a partner has no mental health diagnosis 1.6X greater odds of divorce (Kessler et al., 1998) 3.8X greater odds of marital distress (Whisman et al., 1999)

5. Intimate Relationships and PTSD in Prior Eras PTSD versus Trauma-Exposed/No PTSD More divorce More intimate relationship discord Less self-disclosure and intimacy Less parenting satisfaction More domestic aggression (e.g., NVVRS) 33% (PTSD) vs 15% (No PTSD) in past year 4.86 (PTSD) vs 1.32 (No PTSD) average acts in past year Specificity of symptoms in PTSD-intimate relationship connection Avoidance/numbing in satisfaction Hyperarousal in aggression/violence Galovski & Lyons, 2004; Monson, Taft & Fredman, in press

6. Intimate Relationships and PTSD in Iraq and Afghanistan Veterans Follow-up assessment to Land Combat Study (Hoge et al. 2004) 4-fold increase in interpersonal relationship problems (Milliken et al., 2007) Higher than increase in individual psychopathology symptoms (Hoge et al. 2006) Dissociation and general anxiety inversely associated with relationship problems (Nelson Goff et al., 2007) Severity of family problems associated with PTSD and depression in treatment-seeking sample of veterans (Sayers et al., 2009) Interaction of wives’ attributions of combat exposure and husbands’ PTSD symptoms (Renshaw et al, 2008) Monson, Taft & Fredman, in press

7. PTSD Treatment Efficacy Note. Effect sizes are computed from the difference between groups at post-treatment, combining intention-to-treat and completer approaches. Watts et al., 2008

8. Top 5 Reasons for Conjoint Therapy for PTSD You’re doing couple therapy on a wrap-around love seat…. Promising results based on controlled trials of generic behavioral couple/family therapy for PTSD (e.g., Glynn et al., 1999) open trial of disorder-specific CBCT for PTSD (Monson et al., 2004; 2005) Negative family environment associated with worse outcome in individual treatment (e.g., Tarrier et al., 1999) Non-/partial response to existing evidence-based therapies (Bradley et al., 2005) 25-35% drop-out from existing evidence-based therapies (Hembree et al., 2003)

9. The New Yorker, January 5, 2009

10. Types of Conjoint/Family Therapies for Individual Psychopathology Generic Psychoeducation Partner-assisted Disorder-specific

11. control accommodation intimacy satisfaction behavior cognition attributions re: illness emotions threat appraisal anger sad poor communication Significant Other B behavior cognition aggression trust distancing emotions guilt anger numbing Significant Other A cohesion consensus Relationship-level Factors avoidance Monson, Fredman & Dekel, in press

12. control accommodation intimacy satisfaction behavior cognition attributions re: illness emotions poor communication threat appraisal anger sad Partner B behavior cognition aggression trust distancing emotions guilt anger numbing Partner A cohesion consensus Relationship-level Factors Monson, Fredman & Dekel, in press

13. Overview of CBCT for PTSD Disorder-specific intervention Trauma-focused, but not imaginal exposure-based 15 sessions, manualized 1.25-hour sessions Customary inclusion/exclusion criteria for PTSD-identified partner Partner not diagnosed with PTSD Exclusionary criteria specific to relationship Current severe violence Minimal commitment

14. Basic Assumptions Disorder-specific intervention Treating both PTSD and relationship problems ReciprocalAssociation Between PTSD and relationship problems Systemic Addressing system-symptom fit

15. Assessment PTSD Comorbid conditions Relationship Satisfaction and areas of conflict Violence and safety Intimacy and emotional expression Sexual functioning Partner screen Communication Sample

16. Pre-therapy Meeting with each partner and couple together Explicit description of therapy and its course Perhaps different from other therapies received In-session and out-of-session practice Contact outside of sessions Coming to sessions together Disclosure Treatment contracting

17. Conjoint Case 26-year-old OIF veteran and 25-year-old fiancee 3-year relationship history; got together between 2nd and 3rd tour No pre-morbid mental health problems in either partner Fiancee - no current Axis I or II disorders; history of paternal alcoholism Military history Enlisted in Marines after 9/11 3 tours in Iraq (last tour was helicopter machine gunner)

18. Conjoint Case Post-deployment mental health 30% Service Connected for PTSD 5 years of PTSD, EToH dependence/abuse, depression Frequent fighting, including assault charge

19. Stage 3 Stage 2 Stage 1 CBCT for PTSDStages of Treatment

20. Session Overview R • Stage 1: Rationale and Education about PTSD and Relationships • Session 1 Introduction to Treatment • Session 2 Safety Building • Stage 2: Satisfaction Enhancement and Undermining Avoidance • Session 3 Listening and Approaching • Session 4 Sharing Thoughts and Feelings – Emphasis on Feelings • Session 5 Sharing Thoughts and Feelings – Emphasis on Thoughts • Session 6 Getting U.N.S.T.U.C.K. • Session 7 Problem Solving • Stage 3: Making Meaning of the Trauma(s) and End of Therapy • Session 8 Acceptance • Session 9 Blame • Session 10 Trust Issues • Session 11 Power and Control Issues • Session 12 Emotional Closeness • Session 13 Physical Intimacy • Session 14 Post-traumatic Growth • Session 15 Review and Reinforcement of Treatment Gains E S U M E Living

21. Overall Session Structure Check-out Assign OOSA 5 5 OOSA Review 30 25 In-session Practice 10 Introduce new skill or content

22. Stage 1 Introduction to Treatment (#1) Key Content: PTSD as impeded recovery Rationale for treatment Avoidance Meaning making Treatment contracting Key Out-of-Session Practice Assignments Catch Each Other Doing Something Nice Trauma Impact Questions (TIQ)

23. Re-experiencing Hyperarousal Emotional Numbing Avoidance Session #1: Rationale Cycle of Traumatic Stress-related Symptoms

24. Session #1: Rationale Natural Recovery versus Traumatic Stress-related Symptoms/ Posttraumatic Stress Disorder (PTSD)

25. Role Play #1 • As a Triad: • Take turns providing the rationale for the intervention in a conjoint format: • Disorder of impeded recovery • Avoidance as key impediment to recovery • Give feedback prior to exchanging roles: • What worked well? • Any suggestions for improvements?

26. Stage 1 Safety Building (#2) Content Disclosure Negative behaviors Primary prevention Secondary prevention Out-of-session practice Catch Each Other Doing Something Nice Learning About My Anger Time-out and Time-in

27. Trauma Impact Questions 1. How has trauma or PTSD affected our relationship to date? How has it impacted my thoughts, feelings, and behaviors about our relationship? Created a void. At times I just want to be left alone, which drives Leah crazy. She pushes to come in, and I push to be left alone creating arguments and further alienating us from one another. 2. Why did the traumatic event(s) happen to me or my partner? Why is the sky blue? It is part of life, and even if we see these types of situations in movies, we expect them to stay in movies.

28. Stage 2: Behavioral Interventions Communication Skills Training and In Vivo Approach

29. Stage 2:Session Content to Practice OOSA Review Content Listening and Approaching (#3) Sharing: Emphasis on Feelings (#4) Sharing: Emphasis on Thoughts (#5) Getting U.N.S.T.U.C.K. (#6) Problem-solving (#7)

30. Trauma-relevant In-session Practice “What kinds of things would you stop avoiding if you shrunk the role of PTSD in your relationship?” “How can you imagine feeling if you shrunk the role of PTSD in your relationship?” Couple-level In vivo approach New OOSA Check-out Stage 2:Session Content to Practice (cont.)

31. Role Play #2 • As a Triad: • 2 people play dyad and 1 person play therapist coaching dyad in group break-out • Practice Listening/Paraphrasing skill… • With Session #3’s avoidance question (positive): What would we do if we avoided less? • Exchange roles (eenee, meenee, minee, moe..) • Come back together as a group: • What worked well? • What concerns do you have as the therapist intervening?

32. What would we do if we avoided less?

33. Getting U.N.S.T.U.C.K. U = Unified as a team N = Notice and share thoughts and feelings S = (Brain) Storm alternative thoughts T = Table testing U = Use the best C = Changes in emotions and behaviors K = Keep practicing

34. BIG PICTURE U = Unitedand curious N= Notice your thought S = (Brain) Storm alternatives T= Test them out U = Use the best C= Changed feelings and behaviors? K= Keep practicing I didn’t think. I did what I was trained to do. I wish I wouldn’t have had to fire at close range. I had no choice whether or not to fire. Noticed Thought: “I could have chosen not to fire my weapon (at short range).” All things considered I used my best judgment and made the right decision given the situation Most likely the end result would have been much worse had I not fired. C: Less guilt, less sense of individual responsibility; more confidence that I made the right decision. Less self-blame and less likely to second guess myself. K:Often reminding myself that I made the right decision.

35. Stage 3: Cognitive Interventions Trauma-focused Dyadic Cognitive Restructuring

36. Assimilation - pre-existing Trauma I must have done something bad to deserve this It is a just world People can be trusted Beliefs It is my fault STUCK I could have prevented this I am in control

37. Assimilation - pre-existing Trauma I am a bad person People cannot be trusted I deserved it I knew I shouldn’t have trusted him/her Beliefs STUCK See, I have no control I have no control over anything

38. Over-accommodation Betrayal Unsafe Trauma Beliefs Powerless I can’t get close to anyone I can get close to others STUCK The world is safe The world is completely unsafe

39. Accommodation Bad things happen to good people Good people do bad things Betrayal Unsafe Trauma RECOVERY Powerless A different action might have had a bad outcome I have power over many things, but not all things

40. Stage 3 Using U.N.S.T.U.C.K. to address Acceptance (#8) Blame (#9) Trust (#10) Power/Control (#11) Emotional Closeness (#12) Physical Intimacy (#13) Post-traumatic growth (#14) Continuing In vivo approach behaviors

41. Role Play #3 • As a Dyad: • Use the UNSTUCK process to challenge the assimilated stuck point • Work collaboratively with each other • Process with the group how it went

42. BIG PICTURE Noticed Thought: U = Unitedand curious N= Notice your thought S = (Brain) Storm alternatives T= Test them out U = Use the best C= Changed feelings and behaviors? K= Keep practicing “I let her die.” C: K:

43. Stage 3 Final session Review of pre- and post-treatment Trauma Impact Questions (TIQ) Inoculate against inevitable lapses Stress improvements and areas in need of further betterment in review of treatment contract

45. Outcomes of CBCT for PTSD

46. Initial Pilot Sample • 7 Male Vietnam Veterans with PTSD • 5 100% service-connected • 1 50% service-connected • 1 100% SSI • Mean age = 56 years old • 100% Caucasian • Comorbidities • 100% depressed • 5/7 substance abuse/dependence history • Monson et al. (2004). Journal of Traumatic Stress

47. Initial Pilot Sample • Married • 29 years median (2-35 years) • 3 history of physical aggression • 3 previously divorced • Wives • 100% employed • 3 depressed; 1 Bipolar Disorder • 1 PTSD • Monson et al. (2004). Journal of Traumatic Stress

48. Current Sample Characteristics R34 MH076813 (PI: Candice Monson, Ph.D.)

49. Measures Clinician Administered PTSD Scale (CAPS) PTSD Checklist (PCL) patient and partner versions Dyadic Adjustment Scale (DAS) Beck Depression Inventory—II (BDI-II)

50. PTSD Symptoms ** * * * * 1.60 1.47 .64 1.35 1.18 1.56 *p < .05. **p < .01