Key Points
Question
Is participation in family therapy associated with completion of individual therapy among US veterans with posttraumatic stress disorder (PTSD)?
Findings
In this national cohort study of 1 516 887 US veterans diagnosed with PTSD, approximately 4% received any family therapy. Among those who attended at least 1 individual trauma therapy session, those who received trauma-informed or undefined family therapy during their individual trauma-focused treatment were associated with higher odds of completing a minimally adequate dose of individual treatment.
Meaning
These results suggest that integration of trauma-informed family therapy into care for PTSD could help with retention in individual trauma-focused treatment.
This cohort study evaluates whether participation in family therapy is associated with an increased likelihood of completing individual trauma-focused treatment among US veterans with posttraumatic stress disorder.
Abstract
Importance
Despite 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.
Objective
To 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 Participants
This 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.
Exposures
Receipt of any family psychotherapy and subtype of family-based psychotherapy.
Main Outcomes and Measures
Minimally adequate individual trauma-focused treatment completion (ie, 8 or more sessions of trauma-focused treatment in a 6-month period).
Results
Among 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 Relevance
In 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.
Introduction
The Veterans Health Administration (VHA) offers several evidence-based individual trauma-focused treatment options, including prolonged exposure therapy (PE) and cognitive processing therapy (CPT). Both treatments are effective at treating posttraumatic stress disorder (PTSD) in veterans.1,2 However, retention in trauma-focused treatments is a persistent problem (see Edwards-Stewart et al3 for systematic review and meta-analysis). Spouses and partners of veterans diagnosed with PTSD can strongly influence mental health treatment initiation,4,5,6 support treatment retention,7 and may help with treatment motivation.8 A lack of social support strongly contributes to the development and maintenance of PTSD.9 Therefore, engaging a veteran’s immediate social connections could be effective. For example, a recent study6 found that when family members of veterans with PTSD encouraged them to face difficult situations (a key component of trauma-focused treatment), veterans were twice as likely to finish PE or CPT.
Family relationships appear to have a particularly important role among active-duty military service members and veterans who experience greater disruptions in relational functioning due to PTSD symptoms compared with their nonmilitary counterparts. A meta-analysis of 31 studies investigating the associations between indicators of PTSD and intimate relationship problems found that the association between PTSD and relational discord was higher in military samples compared with civilian samples.10 There is strong evidence from systematic reviews documenting the effectiveness of couples therapies for treating adult PTSD and improving interpersonal relationship problems secondary to PTSD symptoms.11,12 However, these reviews were not specific to military or veteran populations. Considering evidence that associations between PTSD symptoms and relationship difficulties are stronger among military couples, and the potential for familial involvement to support veterans’ individual trauma-focused treatment, there is a need to understand how veterans are utilizing family therapy and the effect of family therapy on individual PTSD treatment. Several different family therapies are provided within the VHA; however, whether family treatment modalities differ regarding their potential association with individual PTSD treatment retention is unknown.
The VHA currently offers 3 empirically supported family therapies: (1) integrative behavioral couples therapy (IBCT), (2) behavioral family therapy (BFT), and (3) cognitive-behavioral conjoint therapy (CBCT).13,14,15 IBCT is 11 to 26 sessions, including a 4-session assessment phase before the start of treatment, and has a focus on acceptance between the couple and their relationship behaviors.16,17 BFT is 20 to 25 sessions and focuses on how an individual’s behavior is learned and reinforced in their environment; treatment focuses on changing behavior by changing the environmental feedback.14,17 Lastly, CBCT is 15 sessions and is designed to treat PTSD in a couples setting using principles of cognitive behavioral therapy applied to the couple.17,18,19 In order to understand the utilization of these therapies and test whether participation in each was associated with better outcomes in PTSD treatment, the current study used VHA electronic health record (EHR) data to address 2 research questions. (1) What family therapies are veterans diagnosed with PTSD using? (2) Is participation in family treatment associated with an increased likelihood of completing individual treatment among veterans with PTSD?
Methods
Participants and Procedure
The Veterans Affairs Ann Arbor Healthcare System institutional review board approved this cohort study and waived informed consent to access veterans’ protected health information via the VHA EHR. Informed consent was waived because it would not have been feasible to obtain consent from a very large, retrospective sample of patients. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.20
The VHA Informatics and Computing Infrastructure was used to extract EHR data from the corporate data warehouse (CDW) for all participants in the cohort. In addition to patient demographic information, the CDW contains Current Procedural Terminology and diagnosis codes for outpatient encounters and inpatient stays. The cohort for this study was defined as VHA patients diagnosed with PTSD between October 1, 2015, and December 31, 2019. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis codes were used to identify patients who were diagnosed with PTSD in either an inpatient or outpatient setting during this period (see eTable 1 in Supplement 1 for a list of relevant ICD-10 codes).
Measures
The primary outcome was completion of a minimally adequate course of evidence-based psychotherapy (EBP) for PTSD (attended at least 8 sessions within a 6-month period). Although Current Procedural Terminology codes identify psychotherapy encounters, they are insufficient for determining specific treatment types. To support standardized delivery and tracking of EBPs in the VHA, clinicians are encouraged to use specific medical record note templates that identify the type of EBP within the health factors data field of the CDW. We queried this field to identify delivery of either PE or CPT, the 2 EBPs for PTSD with standardized note templates in the VHA. Patients who received at least 8 individual psychotherapy encounters for PE or CPT within any 6-month period were considered to have received a minimally adequate course of EBP for PTSD.
The primary independent variable was receipt of couples or family-based psychotherapy as determined by Current Procedural Terminology codes during the PE or CPT (see eTable 2 in Supplement 1 for a list of relevant Current Procedural Terminology codes). Evidence-based couples or family-based psychotherapy could consist of IBCT, BFT, or CBCT. We queried the health factors field for specific terms aligned with the national standardized note templates for IBCT and BFT (see eTable 3 in Supplement 1 for the list of family-based search terms used). However, there is no standardized note template for CBCT therapy for PTSD. To capture these visits, we searched for terms in the note contents (eg, “CBCT” or “Cognitive Behavioral Conjoint Therapy”) and excluded notes that contained the CBCT acronym but were not related to couples therapy (eg, excluded terms such as “dental” or “radiation”). Following an iterative process of refining these terms, we achieved 100% accuracy in pulling CBCT notes in a sample of 200 manually reviewed notes. Any veteran who had a Current Procedural Terminology code for couples or family therapy but was not included in our search for BFT, IBCT, or CBCT therapy was categorized as unspecified family therapy.
Demographic characteristics potentially associated with completing a minimally adequate course of individual psychotherapy treatment included age (continuous), sex (male vs female), and race (Black vs White vs other [American Indian or Alaska Native, Asian, Pacific Islander, other]); these variables were obtained from the EHR. Participants’ zip codes were also extracted and then merged with Rural-Urban Commuting Area code data from the US Department of Agriculture so that we could determine whether they lived in an urban or rural area (rural [codes 7-10], suburban [codes 4-6], urban [codes 1-3]). Military service history (including combat exposure and history of military sexual trauma) and service-connected disability (dichotomized into <50% vs ≥50% as a total disability rating that is on deciles, and it is not a continuous rating21) were also extracted from the EHR. Our model also assessed for comorbid psychiatric diagnoses, including depression, anxiety, substance use disorder, schizophrenia, bipolar disorder, and psychosis. All comorbid conditions were identified in the EHR using ICD-10 codes. Lastly, we controlled receipt of other non-EBP psychotherapy visits (ie, case management) as an indicator of general mental health service utilization (see eTable 2 in Supplement 1 for Current Procedural Terminology codes used).
Statistical Analysis
Descriptive statistics were calculated for all variables in the data set; summary statistics (eg, mean [SD], median [IQR]) were calculated for continuous variables, whereas frequency tables were compiled for categorical variables. We created an indicator variable for missing data for any of the included variables, and younger age was the only variable associated with any missing data. Multivariable logistic regression was used to assess whether veterans with PTSD who received couples or family-based psychotherapy treatment were more likely to complete a minimally adequate course of individual psychotherapy treatment. Factors in the model included type of couples or family-based treatment (if any was received during or after their individual trauma-focused treatment), and we included all measured patient characteristics as covariates. We conducted supplemental analyses in which we treated number of individual trauma treatment sessions as a continuous variable and used Poisson regression to model the count of individual psychotherapy sessions completed over 6 months (see eTable 4 in Supplement 1). Two-sided P < .05 was considered statistically significant. Analyses were conducted using SAS Enterprise Guide version 7.1 (SAS Institute) from May to August 2023.
Results
Demographic Characteristics, Military Service History, and Comorbid Conditions
The cohort consisted of 1 516 887 US veterans with VHA patient data who were newly diagnosed with PTSD between October 1, 2015, and December 31, 2019; 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 (Table 1). With respect to comorbid conditions, 363 183 veterans (24.0%) were also diagnosed with depression, 496 065 (32.7%) with an anxiety disorder, 377 035 (24.9%) with a substance use disorder, and 162 306 (10.7%) with bipolar disorder, psychosis, or schizophrenia. We identified 239 238 veterans (21.6%) with a history of combat exposure, 152 037 (10.2%) had a history of military sexual trauma, and 1 220 652 (80.5%) had a service-connected disability rating greater than or equal to 50%.
Table 1. Descriptive Statistics of Study Participants.
| Variable | Participants, No. (%) | |
|---|---|---|
| Whole cohort (N = 1 516 887) | Received family therapy subcohort (n = 58 653) | |
| Gender | ||
| Male | 1 322 592 (87.2) | 50 907 (86.8) |
| Female | 194 295 (12.8) | 7746 (13.2) |
| Race | ||
| Black | 334 645 (23.5) | 10 878 (19.5) |
| White | 1 006 168 (70.5) | 41 572 (74.6) |
| Othera | 86 176 (6) | 3291(5.9) |
| Age, mean (SD), y | 53 (15.9) | 49 (15.4) |
| Living area type | ||
| Rural | 134 172 (8.9) | 4891 (8.4) |
| Suburban | 167 649 (11.2) | 6301 (10.8) |
| Urban | 1 201 902 (79.9) | 47 066 (80.8) |
| Depression | ||
| No | 1 153 705 (76.1) | 37 719 (64.3) |
| Yes | 363 183 (23.9) | 20 934 (35.7) |
| Anxiety | ||
| No | 1 020 823 (67.3) | 32 012 (54.6) |
| Yes | 496 065 (32.7) | 26 641 (45.4) |
| Substance use | ||
| No | 1 139 853 (75.1) | 38 357 (65.4) |
| Yes | 377 035 (24.9) | 20 296 (34.6) |
| Other mental health disorder | ||
| No | 1 354 582 (89.3) | 48 512 (82.7) |
| Yes | 162 306 (10.7) | 10 141 (17.3) |
| Service-connected disability | ||
| 0%-40% | 296 236 (19.5) | 7281(12.4) |
| 50%-100% | 1 220 652 (80.5) | 51 372 (87.6) |
| History of military sexual trauma | ||
| No | 1 339 901 (89.8) | 51 213 (88.4) |
| Yes | 152 037 (10.2) | 6722 (11.6) |
| Combat exposure | ||
| No | 868 417 (78.4) | 33 797 (78.3) |
| Yes | 239 238 (21.6) | 9380(21.7) |
| Family therapy type received | ||
| None | 1 458 235 (96.1) | NA |
| IBCT only | 5210 (0.3) | 5210 (8.9) |
| CBCT only | 15 528 (1) | 15 528 (26.5) |
| BFT only | 282 (0.02) | 282 (0.48) |
| Multiple types of family therapy | 720 (0.05) | 720 (1.2) |
| Family therapy undefined | 36 913 (2.4) | 36 913 (62.9) |
| Minimally adequate does of PE or CPT (≥8 sessions) | ||
| No | 1 352 431 (89.2) | 48 092 (81.9) |
| Yes | 164 457 (10.8) | 10 561 (18) |
| At least 1 non-evidence-based practice mental health therapy session received | ||
| No | 660 500 (43.5) | 6120 (10.4) |
| Yes | 856 388 (56.5) | 52 533 (89.6) |
Abbreviations: BFT, behavioral family therapy; CBCT, cognitive-behavioral conjoint therapy; CPT, cognitive processing therapy; IBCT, integrative behavioral couples therapy; PE, prolonged exposure therapy; NA, not applicable.
Other race category included American Indian or Alaska Native (n = 21 104), Asian (n = 20 279), Pacific Islander (n = 19 094), and other/unknown (n = 25 699).
Among all cohort patients, 58 653 veterans (3.9%) received any family therapy; of these, 50 907 (86.8%) were male, 41 572 (74.6%) were White, 47 066 (80.8%) lived in urban locations; and 37 719 (64.3%) were not coping with depression (64.3%), 32 012 (54.6%) were not coping with anxiety, and 38 357 (65.4%) were not coping with substance use, and 48 512 (82.7%) were not coping with some other mental health disorder; 51 213 (88.4%) were not identified as having experienced military sexual trauma and 33 797 (78.3%) were not exposed to combat. Furthermore, 51 372 (87.6%) received more than or equal to 50% in total disability rating, and 52 533 (89.6%) had attended at least 1 other non-EBP treatment.
Within this subcohort of veterans who received any family therapy, there were 5210 (8.9%) who received IBCT therapy only, 15 528 (26.5%) who received CBCT therapy only, 282 (0.5%) who received BFT therapy only, 720 veterans (1.2%) who received more than 1 type of family therapy. There were 36 913 patients (62.9%) who received couples or family-based treatment based on Current Procedural Terminology codes, but the specific type of therapy was not indicated; and 10 561 veterans (18.0%) completed a minimally adequate amount of individual psychotherapy for PTSD.
Statistical Analysis Results
Logistic regression was used to estimate a minimally adequate treatment of individual psychotherapy for PTSD among the 1 018 843 veterans who attended at least 1 treatment session (Table 2). Compared with receiving no family therapy care, veterans were more likely to complete a minimally adequate dose of individual PTSD treatment if they were also receiving CBCT (7% more likely; OR, 1.07 [95% CI, 1.01-1.13]), or undefined family therapy (68% more likely; OR, 1.68 [95% CI, 1.63-1.74]). However, veterans were 26% less likely (OR, 0.74 [95% CI, 0.66-0.82]) to complete a minimally adequate dose of individual PTSD treatment if they were also receiving IBCT compared with veterans receiving no family therapy care.
Table 2. Multivariable Logistic Regression Analysis Estimating Completion of a Minimally Adequate Dose of Individual PTSD Psychotherapy.
| Variable | β (95% CI) | OR (95% CI) | P value |
|---|---|---|---|
| Intercept | −3.37 (NA) | NA | <.001 |
| Family therapy type (vs no family therapy) | |||
| IBCT only | −0.31 (−0.42 to −0.20) | 0.74 (0.66 to 0.82) | <.001 |
| CBCT only | 0.07 (0.01 to 1.12) | 1.07 (1.01 to 1.13) | .03 |
| BFT only | 0.33 (−0.01 to 0.67) | 1.39 (0.99 to 1.96) | .06 |
| Multiple types | 0.02 (−0.24 to 0.28) | 1.02 (0.79 to 1.32) | .89 |
| Undefined | 0.52 (0.49 to 0.55) | 1.68 (1.63 to 1.74) | <.001 |
| Race (vs White) | |||
| Black | −0.02 (−0.04 to −0.01) | 0.98 (0.96 to 0.99) | .002 |
| Othera | −0.12 (−0.15 to −0.09) | 0.89 (0.86 to 0.91) | <.001 |
| Gender (vs male) | |||
| Female | 0.10 (0.08 to 0.12) | 1.10 (1.08 to 1.13) | <.001 |
| Age at first therapy appointment | 0.01 (0.01 to 0.01) | 1.01 (1.01 to 1.01) | <.001 |
| Living area type (vs rural) | |||
| Suburban | −0.03 (−0.05 to 0) | 0.97 (0.95 to 1.00) | .047 |
| Urban | −0.10 (−0.13 to −0.08) | 0.90 (0.88 to 0.92) | <.001 |
| Depression (vs no) | 0.33 (0.32 to 0.35) | 1.40 (1.38 to 1.42) | <.001 |
| Anxiety (vs no) | 0.21 (0.19 to 0.22) | 1.23 (1.21 to 1.25) | <.001 |
| Substance use disorder (vs no) | 0.62 (0.61 to 0.64) | 1.87 (1.84 to 1.89) | <.001 |
| Other mental health disorder (vs no) | 0.64 (0.63 to 0.66) | 1.90 (1.87 to 1.93) | <.001 |
| Service-connected disability 50%-100% (vs 0%-40%) | 0.01 (−0.01 to 0.03) | 1.01 (0.99 to 1.03) | .28 |
| History of military sexual trauma (vs no) | 0.39 (0.37 to 0.42) | 1.48 (1.45 to 1.52) | <.001 |
| History of combat exposure (vs no) | −0.18 (−0.20 to −0.17) | 0.84 (0.82 to 0.85) | <.001 |
| At least 1 non–evidence-based practice mental health therapy session received (vs no) | 0.48 (0.46 to 0.49) | 1.61 (1.59 to 1.63) | <.001 |
Abbreviations: BFT, behavioral family therapy; CBCT, cognitive-behavioral conjoint therapy; IBCT, integrative behavioral couples therapy; NA, not applicable.
Other race category included American Indian or Alaska Native (n = 21 104), Asian (n = 20 279), Pacific Islander (n = 19 094), and other/unknown (n = 25 699).
In terms of demographic factors, veterans who were Black (OR, 0.98 [95% CI, 0.96-0.99]) or other minoritized race (OR, 0.89 [95% CI, 0.86-0.91) were slightly less likely to complete a minimally adequate dose of individual therapy compared with White veterans; and compared with male veterans, female veterans were more likely to complete a minimally adequate dose of individual therapy (OR, 1.10 [95% CI, 1.08-1.13]). For each 1-year increase in age, veterans were slightly more likely to complete a minimally adequate dose of treatment (OR, 1.01 [95% CI, 1.01-1.01]). Veterans living in urban areas were less likely (OR, 0.90 [95% CI, 0.88-0.92]), and veterans living in suburban areas were slightly less likely (OR, 0.98 [95% CI, 0.95-1.00) compared with patients living in rural areas. Veterans were more likely to complete a minimally adequate dose of individual trauma-focused therapy if they were diagnosed with depression (OR, 1.42 [95% CI, 1.40-1.43]), anxiety disorders (OR, 1.22 [95% CI, 1.20-1.24]), substance use disorders (OR, 1.87 [95% CI, 1.84-1.89]), or with bipolar disorder, psychosis, or schizophrenia (OR, 1.92 [95% CI, 1.89-1.95]) compared with veterans without these diagnoses.
Veterans with a history of military sexual trauma had 52% greater odds to complete a minimally adequate dose of individual trauma-focused therapy (OR, 1.52 [95% CI, 1.49-1.56]), and veterans with a history of combat exposure had 16% reduced odds to complete (OR, 0.84 [95% OR, CI, 0.83-0.85]) compared with those who did not have these histories. Lastly, veterans engaged in at least 1 non-EBP were more likely to have a minimally adequate dose of individual trauma-focused treatment (OR, 1.61 [95% CI, 1.59-1.63]).
Discussion
In a cohort of more than 1.5 million VHA patients with PTSD, we found only approximately 4% had participated in any kind of couples or family therapy. As of 2020, about half of all military personnel were married, and about a third had at least 1 child, indicating a majority of veterans may have a close family member who could be included in treatment.22 Furthermore, prior work suggests that veterans have a preference for including their family in treatment for PTSD23,24,25 and VHA clinicians also have positive views regarding the importance of family-level treatment adjunctive to individual treatment for PTSD.26 Recent VHA data on the utilization of family therapy in mental health clinics shows that VHA patients diagnosed with PTSD report receiving more of any type of family therapy compared with those diagnosed with other mental health conditions.27 Additionally, there is strong evidence from systematic reviews documenting the effectiveness of couples therapies for treating adult PTSD and improving interpersonal relationship problems secondary to PTSD symptoms.11,12,28 Given the research linking PTSD and relational discord in veteran populations, this finding suggests potential underutilization of trauma-informed family therapy among VHA patients.
Although the specific therapy could not be identified for 63% of those who received couples/family treatment, CBCT was used most frequently among identifiable interventions (27%). Since there is not a standardized note template within the VHA to formally track clinicians using CBCT, there is a chance that some of the notes in the undefined family therapy category are CBCT. Veterans who participated in CBCT were more likely to complete a minimally adequate course of individual trauma-focused treatment. CBCT is the only family-based intervention offered in the VHA that has a PTSD focus, so it is unsurprising that it would be used the most in this cohort of veterans diagnosed with PTSD. This treatment directly involves the partner into the PTSD treatment in 3 phases over 15 sessions: (1) psychoeducation about PTSD and relationship safety, (2) communication skills and decreasing avoidance and emotional numbing, and (3) challenging trauma-related cognitions termed “stuck points.”29 These findings support the use of CBCT to help veterans in completing a minimally adequate course of individual trauma-focused treatment. Furthermore, these findings suggest the VHA should make efforts to support clinicians in reporting on the specific family therapies they are using (eg, rolling out a standardized note template for CBCT) as well as provide more training, consultation, and support for the delivery of this therapy.
Unexpectedly, we found that veterans diagnosed with PTSD and who attended at least 1 session of IBCT during their course of individual trauma-focused treatment were less likely to complete individual trauma-focused treatment. IBCT is not a trauma-focused treatment, rather it focuses on the health of the relationship overall. This finding could indicate that when a veteran diagnosed with PTSD is undergoing individual trauma-focused treatment, the addition of a separate evidence-based treatment may interfere with the veteran’s ability to complete their individual trauma care. Alternatively, veterans may experience substantial improvement in their functioning when undergoing ICBT, such that they do not need as much individual trauma-focused treatment. Because relationship issues are a key motivator for PTSD treatment engagement, veterans may prioritize relationship-focused issues if they are not accounted for within PE or CPT. To answer these questions, additional work is needed that assesses PTSD symptoms and functioning for veterans undergoing concurrent family therapy and individual trauma-focused treatment.
The potential for CBCT to increase adequate engagement in PE or CPT is important because retention in outpatient PTSD treatment is low3,30 and treatment retention in an individual course of therapy for PTSD is much more likely to result in a significant reduction in PTSD symptoms.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 can improve treatment retention in individual therapy.7 Further research is needed to better understand the associations between family therapies and PTSD symptoms, functioning, and quality of life outcomes in the VHA. Additionally, future research should focus on the mechanisms behind how these therapies might improve engagement and comparative effectiveness studies between the different types of family treatments offered. Additional research could help determine if it is better when the family is involved in the PTSD treatment itself or if receiving therapy for relationship issues helps improve individual PTSD treatment retention.
Limitations
This study had limitations. The use of EHR data provided access to a very large sample of VHA patients; however, due to the lack of standardized methods for recording the type of couples and family therapy provided, the automated search term strategy used was not able to identify the type of couple or family therapy for approximately 63% of patients who participated in family-level treatment. There is also a chance that veterans could have had a family session in their PE or CPT treatment that was not documented in Current Procedural Terminology codes we searched. Due to the observational nature of the study, we were unable to make causal inferences regarding the effect of couples or family therapy on PE or CPT completion. Though small-scale randomized clinical trial evidence supports trauma-informed family treatment as being effective for individual treatment completion,2 it is also possible that factors such as perceived need for treatment or treatment acceptability may explain why patients who seek out trauma-informed couples or family therapy are more likely to complete individual treatment. The current study did not account for severity of PTSD symptoms. A recent study of Operation Enduring Freedom and Operation Iraqi Freedom veterans found that more severe PTSD symptoms were associated with a greater likelihood of family-involved care.23 Perhaps veterans with less severe symptoms are less in need of family treatment because their symptoms are not as detrimental to the functioning of the relationship.
Conclusions
This study’s findings from a very large cohort of VHA patients diagnosed with PTSD suggest that trauma-informed family-level therapies are possibly underutilized but may be helpful in terms of their potential to support adequate engagement in effective individual treatment for PTSD. These findings support growing calls to evaluate the effectiveness of and increased provision of family-based services to veterans with PTSD through the VHA,23,33,34,35 recommendations which were included in the Institute of Medicine’s seminal report on the treatment of PTSD among military and veteran populations more than a decade ago in 2012.36
eTable 1. Posttraumatic Stress Disorder International Classification of Diseases 10 Codes (ICD10) Used in Analyses
eTable 2. List of Current Procedural Terminology (CPT) for Couples/Family-Based Psychotherapy With the Veterans Health Administration
eTable 3. Health Factors Field and Note Content Search Terms for Evidence-Based Family Therapy Within the Veterans Health Administration
eTable 4. Poisson Regression Output Estimating Individual PTSD Psychotherapy Session Count
Data Sharing Statement
References
- 1.Steenkamp MM, Litz BT, Hoge CW, Marmar CR. Psychotherapy for military-related PTSD: a review of randomized clinical trials. JAMA. 2015;314(5):489-500. doi: 10.1001/jama.2015.8370 [DOI] [PubMed] [Google Scholar]
- 2.Thompson-Hollands J, Strage M, DeVoe ER, Beidas RS, Sloan DM. Development and initial testing of a brief adjunctive intervention for family members of veterans in individual PTSD treatment. Cogn Behav Pract. 2021;28(12):193-209. doi: 10.1016/j.cbpra.2020.06.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Edwards-Stewart A, Smolenski DJ, Bush NE, et al. Posttraumatic stress disorder treatment dropout among military and veteran populations: a systematic review and meta-analysis. J Trauma Stress. 2021;34(4):808-818. doi: 10.1002/jts.22653 [DOI] [PubMed] [Google Scholar]
- 4.Meis LA, Barry RA, Kehle SM, Erbes CR, Polusny MA. Relationship adjustment, PTSD symptoms, and treatment utilization among coupled National Guard soldiers deployed to Iraq. J Fam Psychol. 2010;24(5):560-567. doi: 10.1037/a0020925 [DOI] [PubMed] [Google Scholar]
- 5.Spoont MR, Nelson DB, Murdoch M, et al. Impact of treatment beliefs and social network encouragement on initiation of care by VA service users with PTSD. Psychiatr Serv. 2014;65(5):654-662. doi: 10.1176/appi.ps.201200324 [DOI] [PubMed] [Google Scholar]
- 6.Meis LA, Noorbaloochi S, Hagel Campbell EM, et al. Sticking it out in trauma-focused treatment for PTSD: it takes a village. J Consult Clin Psychol. 2019;87(3):246-256. doi: 10.1037/ccp0000386 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Thompson-Hollands J, Lee DJ, Sloan DM. The use of a brief family intervention to reduce dropout among veterans in individual trauma-focused treatment: a randomized controlled trial. J Trauma Stress. 2021;34(4):829-839. doi: 10.1002/jts.22680 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Shepherd-Banigan M, Shapiro A, Sheahan KL, et al. 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. Psychol Serv. 2023;20(4):839-848. doi: 10.1037/ser0000742 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull. 2003;129(1):52-73. doi: 10.1037/0033-2909.129.1.52 [DOI] [PubMed] [Google Scholar]
- 10.Taft CT, Watkins LE, Stafford J, Street AE, Monson CM. Posttraumatic stress disorder and intimate relationship problems: a meta-analysis. J Consult Clin Psychol. 2011;79(1):22-33. doi: 10.1037/a0022196 [DOI] [PubMed] [Google Scholar]
- 11.Sijercic I, Liebman RE, Ip J, et al. A systematic review and meta-analysis of individual and couple therapies for posttraumatic stress disorder: clinical and intimate relationship outcomes. J Anxiety Disord. 2022;91:102613. doi: 10.1016/j.janxdis.2022.102613 [DOI] [PubMed] [Google Scholar]
- 12.Suomi A, Evans L, Rodgers B, Taplin S, Cowlishaw S. Couple and family therapies for post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2019;12(12):CD011257. doi: 10.1002/14651858.CD011257.pub2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Christensen A, Atkins DC, Yi J, Baucom DH, George WH. Couple and individual adjustment for 2 years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. J Consult Clin Psychol. 2006;74(6):1180-1191. doi: 10.1037/0022-006X.74.6.1180 [DOI] [PubMed] [Google Scholar]
- 14.Griffin WA, Greene SM. Behavioral family therapy. In: Models of Family Therapy. 1st ed . Routledge; 2021:43-52. [Google Scholar]
- 15.Macdonald A, Pukay-Martin ND, Wagner AC, Fredman SJ, Monson CM. Cognitive-behavioral conjoint therapy for PTSD improves various PTSD symptoms and trauma-related cognitions: results from a randomized controlled trial. J Fam Psychol. 2016;30(1):157-162. doi: 10.1037/fam0000177 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Benson LA, Christensen A. Traditional and integrative behavioral couple therapy. Handb Fam Ther. 2019;(November):349-360. doi: 10.4324/9780203123584-18 [DOI] [Google Scholar]
- 17.U.S. Department of Veterans Affairs . Evidence-based treatment - mental health. Published September 9, 2022. Accessed April 12, 2023. https://www.mentalhealth.va.gov/get-help/treatment/ebt.asp
- 18.Pukay-Martin ND, Fredman SJ, Martin CE, et al. Effectiveness of cognitive behavioral conjoint therapy for posttraumatic stress disorder (PTSD) in a U.S. Veterans Affairs PTSD clinic. J Trauma Stress. 2022;35(2):644-658. doi: 10.1002/jts.22781 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Monson CM, Fredman SJ, Adair KC, et al. Cognitive-behavioral conjoint therapy for PTSD: pilot results from a community sample. J Trauma Stress. 2011;24(1):97-101. doi: 10.1002/jts.20604 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453-1457. doi: 10.1016/S0140-6736(07)61602-X [DOI] [PubMed] [Google Scholar]
- 21.US Department of Veterans Affairs . Compensation: benefit rates. Accessed August 10, 2023. https://www.benefits.va.gov/compensation/rates-index.asp
- 22.Department of Defense . 2020 Demographics profile of the military community. Accessed November 22, 2022. https://www.icf.com/work/human-capital
- 23.Harper KL, Thompson-Hollands J, Keane TM, Marx BP. Family-involved mental health care among OEF/OIF veterans with and without PTSD using VHA administrative records. Behav Ther. 2022;53(5):819-827. doi: 10.1016/j.beth.2022.01.006 [DOI] [PubMed] [Google Scholar]
- 24.Batten S, Drapalski L, Decker L, et al. Veteran interest in family involvement in PTSD treatment. Psychol Serv. 2009;6(3):184-189. doi: 10.1037/a0015392 [DOI] [PubMed] [Google Scholar]
- 25.Meis LA, Schaaf KW, Erbes CR, et al. Interest in partner-involved services among veterans seeking mental health care from a VA PTSD clinic. Psychol Trauma. 2013;5:334-342. doi: 10.1037/a0028366 [DOI] [Google Scholar]
- 26.Thompson-Hollands J, Rando AA, Stoycos SA, Meis LA, Iverson KM. Family involvement in PTSD Treatment: perspectives from a nationwide sample of Veterans Health Administration clinicians. Adm Policy Ment Health. 2022;49(6):1019-1030. doi: 10.1007/s10488-022-01214-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.McKee GB, McDonald SD, Karmarkar A, Ghatas MP. Demographic characteristics, mental health conditions, and psychotherapy use of veterans in couples and family therapy. Couple Fam Psychol Res Pract. 2023;12(1):11-23. doi: 10.1037/cfp0000185 [DOI] [Google Scholar]
- 28.Malaktaris AL, Buzzella BA, Siegel ME, et al. OEF/OIF/OND Veterans seeking PTSD treatment: perceptions of partner involvement in trauma-focused treatment. Mil Med. 2019;184(3-4):e263-e270. doi: 10.1093/milmed/usy231 [DOI] [PubMed] [Google Scholar]
- 29.Monson CM, Schnurr PP, Stevens SP, Guthrie KA. Cognitive-behavioral couple's treatment for posttraumatic stress disorder: initial findings. J Trauma Stress. 2004;17(4):341-344. doi: 10.1023/B:JOTS.0000038483.69570.5b [DOI] [PubMed] [Google Scholar]
- 30.Grau PP, Bohnert KM, Ganoczy D, Sripada RK. Who improves in trauma-focused treatment: a cluster analysis of treatment response in VA patients undergoing PE and CPT. J Affect Disord. 2022;318:159-166. doi: 10.1016/j.jad.2022.08.126 [DOI] [PubMed] [Google Scholar]
- 31.Rutt BT, Oehlert ME, Krieshok TS, Lichtenberg JW. Effectiveness of cognitive processing therapy and prolonged exposure in the Department of Veterans Affairs. Psychol Rep. 2018;121(2):282-302. doi: 10.1177/0033294117727746 [DOI] [PubMed] [Google Scholar]
- 32.Meis LA, Glynn SM, Spoont MR, et al. Can families help veterans get more from PTSD treatment? A randomized clinical trial examining Prolonged Exposure with and without family involvement. Trials. 2022;23(1):243. doi: 10.1186/s13063-022-06183-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Creech SK, Brown EK, Saenz JJ, et al. Addressing parent–child functioning problems in veterans with posttraumatic stress disorder: Veterans affairs provider practices and perspectives. Couple Fam Psychol Res Pract. 2019;8:105-120. doi: 10.1037/cfp0000122 [DOI] [Google Scholar]
- 34.Glynn SM. Family-centered care to promote successful community reintegration after war: it takes a nation. Clin Child Fam Psychol Rev. 2013;16(4):410-414. doi: 10.1007/s10567-013-0153-z [DOI] [PubMed] [Google Scholar]
- 35.Pemberton JR, Kramer TL, Borrego J Jr, Owen RR. Kids at the VA? a call for evidence-based parenting interventions for returning veterans. Psychol Serv. 2013;10(2):194-202. doi: 10.1037/a0029995 [DOI] [PubMed] [Google Scholar]
- 36.Institute of Medicine . Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. National Academies Press; 2012. doi: 10.17226/13364 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Posttraumatic Stress Disorder International Classification of Diseases 10 Codes (ICD10) Used in Analyses
eTable 2. List of Current Procedural Terminology (CPT) for Couples/Family-Based Psychotherapy With the Veterans Health Administration
eTable 3. Health Factors Field and Note Content Search Terms for Evidence-Based Family Therapy Within the Veterans Health Administration
eTable 4. Poisson Regression Output Estimating Individual PTSD Psychotherapy Session Count
Data Sharing Statement
