Development and initial testing of a brief adjunctive intervention for family members of veterans in individual PTSD treatment

Abstract

Family involvement in the treatment of posttraumatic stress disorder (PTSD) among veterans has the potential to improve treatment retention and outcomes. Current protocols that incorporate family members into treatment tend to involve at least 15 sessions, and none are designed to complement Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE), the two most widely used and heavily promoted evidence-based PTSD therapies in the Veterans Affairs (VA) healthcare system. The current paper describes the development and initial feasibility and acceptability of a Brief Family Intervention (the BFI) designed to be delivered as an adjunct to veterans’ individual CPT/PE. The BFI focuses on providing psychoeducation about PTSD and treatment, building family member support for treatment, and reducing family symptom accommodation. A detailed review of the treatment structure and activities is provided, and qualitative data from four dyads (veterans and their spouses/significant others) at baseline and post-intervention are presented. Veterans and partners reported positive responses to the program and were enthusiastic about its utility. Larger randomized controlled studies will be needed to determine the protocol’s efficacy and effectiveness.

Posttraumatic stress disorder (PTSD) among service members and veterans is a common problem (Kok, Herrell, Thomas, & Hoge, 2012). While a number of treatment options for PTSD exist, emerging evidence suggests that these treatments are less effective among veteran and service member populations compared to civilians (Steenkamp, Litz, Hoge, & Marmar, 2015), and dropout rates among veterans are also higher (Kehle-Forbes, Meis, Spoont, & Polusny, 2016). Social support, which has been shown to be one of the most influential factors in terms of PTSD symptom severity (e.g., Brewin, Andrews, & Valentine, 2000), is an environmental factor that could be leveraged to significantly improve veterans’ treatment outcomes (Tarrier et al., 1999). Work in other anxiety-related disorders such as obsessive-compulsive disorder and agoraphobia has shown that a couple- or family-based approach produces superior outcomes when compared to individual treatment alone (Barlow, O’Brien, & Last, 1984; Cerny, Barlow, Craske, & Himadi, 1987; Thompson-Hollands, Abramovitch, Tompson, & Barlow, 2015). Meta-analyses confirm that lack of social support is one of the strongest contributors to the development and maintenance of PTSD, and this relationship is especially robust among individuals with combat trauma (Ozer, Best, Lipsey, & Weiss, 2008). Because of the importance of interpersonal connection and the perniciousness of the disorder in terms of its impact on the interpersonal system, family support is a critical area to target among veterans with PTSD.

In addition to the potential benefits that family members can provide in terms of veterans’ treatment, incorporating significant others into treatment may prevent them from undermining the treatment in various ways. For example, without proper psychoeducation or orientation to the model of trauma-focused treatment for PTSD, family members may object to treatment activities that involve directly confronting traumatic memories and fully experiencing the resulting emotions. Even clinicians themselves, especially those with less training or experience, can view exposure-based treatment for PTSD as harmful or not credible (Becker, Zayfert, & Anderson, 2004; Frueh, Cusack, Grubaugh, Sauvageot, & Wells, 2006), thus it is reasonable to assume that some portion of family members will also be skeptical of or even alarmed by the requirements of trauma-focused therapy. If family members are sufficiently concerned, they may encourage the veteran to discontinue prematurely rather than proceed with what the family member views as risky or damaging treatment activities.

Additionally, families may be engaging in significant symptom accommodation, meaning changes to their own behavior in order to reduce or prevent disorder-related distress in the veteran. Although often driven by compassion or by simple practical concerns (Boeding et al., 2013; Calvocoressi et al., 1995, 1999; Thompson-Hollands, Kerns, Pincus, & Comer, 2014), accommodation ultimately reinforces the disorder pathology by allowing patients to avoid their emotional experience. In PTSD, accommodation may involve family behaviors like avoiding topics of conversation related to the military or combat, or doing all of the family’s shopping because the veteran feels unable to tolerate crowded stores (Fredman, Vorstenbosch, Wagner, Macdonald, & Monson, 2014). Accommodation is associated with patients’ levels of PTSD symptoms and relationship distress (Fredman et al., 2014). Furthermore, accommodation conflicts with a fundamental goal of current gold-standard treatments for PTSD: patients allowing themselves to experience and accept their emotions surrounding the trauma, and the elimination of trauma-related avoidance (Foa, Hembree, & Rothbaum, 2007; Resick, Monson, & Chard, 2014). By undermining a key mechanism of PTSD treatment, family accommodation effectively reduces the “dose” of treatment that veterans are receiving in their daily lives. A recent study by Campbell and colleagues (Campbell, Renshaw, Kashdan, Curby, & Carter, 2017) found evidence of a bi-directional relationship between PTSD symptoms and accommodation: PTSD symptoms among military service members predicted later accommodation by romantic partners, and partners’ earlier accommodation behaviors contributed specifically to service members’ later avoidance symptoms. Taken together it is clear that accommodation, and family support for a trauma-focused treatment approach more broadly, are especially important targets as veterans begin a course of treatment.

Existing Family-Inclusive Treatments

In recognition of the association between PTSD symptoms and family functioning, a handful of family-inclusive treatments for PTSD have been developed. Some of these are specifically designed for spouses or romantic partners (e.g., Emotionally Focused Couple Therapy for Trauma (Johnson, 2002), Structured Approach Therapy (Sautter, Glynn, Cretu, Senturk, & Vaught, 2015)), while others are open to a broader range of family members (e.g., Cognitive-Behavioral Conjoint Therapy (CBCT; Monson & Fredman, 2012); REACH (Fischer, Sherman, Han, & Owen, 2013)). These protocols are intended to be standalone treatments; with the exception of REACH, all contain elements that focus directly on treating the PTSD symptoms (such as exposure) while also providing psychoeducation and elements targeting relationship enhancement (such as communication skills training). The protocols span from 15 to 36 sessions (Monson & Fredman, 2012; Weissman et al., 2017) and as long as 9 months (Sherman et al., 2013).

Having the family member present for all portions of the treatment, particularly for any exposure-based portions, likely enhances the family member’s understanding of the rationale for exposure and may allow the veteran to feel more supported by their relative. However, designing the protocol to be fully conjoint means that both veterans and family members must be able to commit to many months of weekly appointments. This is a substantial burden and may prove to be impossible for many families; in particular, veterans from the more recent post-9/11 conflicts may be part of dual-working couples or have substantial child or elder care responsibilities.

In addition to limitations on the flexibility of veterans and their families, there are also clinician barriers. Specifically, clinicians may not have the time, training, or inclination to deliver conjoint treatment. In a recent study we conducted qualitative interviews with usual-care VA clinicians who routinely treat veterans with PTSD about their current practices with regard to family-inclusive care (Thompson-Hollands, Strage, Beidas, & Sloan, in preparation). Several respondents noted that they try to avoid “having the session turn into couples’ therapy” and that they needed family interventions to be brief if these treatments were to be feasible, given their clinics’ structure and constraints (e.g., VA mandate to provide evidence-based PTSD treatments, with a particular emphasis on providing Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE)). Although the existing lengthy family-involved treatments may address legitimate problems that veterans and their families face, if those protocols are not realistic in terms of what the healthcare system can accommodate then they will not be used (Klesges, Estabrooks, Dzewaltowski, Bull, & Glasgow, 2005). We therefore sought to develop and test a family-focused intervention that addressed the drawbacks of existing family-inclusive treatments. This study presents an overview of this novel intervention, as well as preliminary feasibility and acceptability data from veteran partner dyads.

The Brief Family Intervention (BFI) for PTSD

Based upon previous work conducted by the first author in the realm of obsessive-compulsive disorder (Thompson-Hollands, Abramovitch, Tompson, & Barlow, 2015) and the limitations of existing family treatments as described above, we developed the Brief Family Intervention (BFI) for PTSD. The BFI is specifically designed to serve as an adjunctive intervention for the family members of veterans who are beginning one of two first-line trauma-focused interventions, CPT or PE. Since 2005 the VA has been engaged in a large-scale effort towards training and dissemination of CPT/PE (Karlin et al., 2010), and it is now VA policy that all veterans with PTSD have access to these treatments. Accordingly, we sought to capitalize on, and enhance, this framework of high-quality PTSD treatment by developing a brief, adjunctive intervention for use with the family members of veterans engaged in one of these two treatments. In addition to leveraging the existing systemic momentum in favor of these two trauma-focused protocols, targeting the family members of veterans in CPT/PE is also consistent with the results from our qualitative work with VA clinicians. In those interviews, clinicians reported that they found it especially important to work with family members in the context of CPT/PE, to orient them to an exposure-based treatment model and prepare them for a possible increase in PTSD symptoms during the initial treatment phase (Thompson-Hollands et al., in preparation).

The BFI is delivered in two 1-hour-long sessions held approximately one week apart, at the beginning of the veteran’s course of CPT/PE. The exact timing of the BFI is flexible in order to maximize convenience for both family members and clinicians, but it is advised that the BFI sessions occur before the veteran has reached the fourth session of CPT/PE. Because dropout from CPT/PE typically occurs within the first part of treatment (Gutner et al., 2016; Kehle-Forbes, Meis, Spoont, & Polusny, 2016), early administration of the BFI is intended to forestall premature termination. Additionally, the psychoeducation provided to the family member, such as orienting them to the treatment model and preparing them for treatment-related activities, is likely to be most useful at the beginning of the veteran’s course of treatment.

The BFI is designed to be applicable to any adult relative or close friend¹ who has regular contact with the veteran and who the veteran agrees to have participate. Veterans are free to choose whomever they wish, provided that the person is an adult and interacts with the veteran regularly. We have no set standard for the level of contact that is necessary for a family member to be “close enough” to the veteran, but instead defer to the clinician’s judgment in terms of the individual’s relationship to the veteran and the amount and intensity of contact that they have with the veteran. The relationship does not have to be free of distress, and in fact this would be quite rare in our experience.

Family members attend the BFI sessions individually; the veteran is not present. This choice serves several purposes. The most significant reason for excluding the veteran is to give the family member an opportunity to be fully honest regarding their experience of living with someone with PTSD. Partners of veterans with PTSD are at risk of elevated psychological distress (Jordan et al., 1992; Manguno-Mire et al., 2007). They experience high levels of caregiver burden, as well as distress on behalf of their loved one (Calhoun et al., 2002). We want family members who participate in the BFI to have the space to acknowledge the difficulties of their situation, without feeling the need to censor themselves to prevent hurt feelings. Additionally, if the veteran is present family members may not be comfortable describing the severity of the veteran’s PTSD or the ways in which the family member is currently accommodating the symptoms. This reluctance to acknowledge the breadth of accommodation would prevent the clinician from fully exploring and working with the family member to reduce these behaviors. Finally, as noted above, some clinicians are not comfortable conducting couples or family sessions; most have not received such training in graduate school and there are few opportunities to conduct these types of sessions within the VA, meaning that providers have little chance to develop or practice these skills. In contrast, psychoeducation and skills-based sessions held one-on-one with a client are a format that will be comfortable to any provider with a background in CBT; electing to conduct the BFI in an individual basis was therefore also a pragmatic choice made with an eye toward maximizing future dissemination. Because the veteran is not present for the sessions, the BFI is delivered by a clinician other than the veteran’s individual provider for CPT/PE. This is necessary for reasons of confidentiality and maintaining trust with the veteran’s individual provider and this “division of responsibility” was a strong preference of the VA clinicians who were interviewed as part of our preliminary protocol development work (Thompson-Hollands et al., in preparation).

The BFI is primarily a psychoeducational intervention in nature; this is both by design (in order to keep the focus narrow) and by necessity (a two-session protocol does not provide much time for skill mastery). However, we consider several elements to have a skill-building component as well, particularly the focus on enhancing communication around PTSD and treatment, as well as the work on identifying and planning to reduce or eliminate accommodation behaviors. These portions of the BFI sessions are often accompanied by role-play conversations with the clinician, in order to rehearse potential future conversations with the veteran. The balance of psychoeducation and skill-building will necessarily vary somewhat depending on the exact presentation of the family system, but the former is always a larger portion of session content relative to the latter.

The goals of the BFI are twofold: To reduce the likelihood of dropout from CPT/PE by increasing family member support for the treatment, and to reduce the veteran’s level of avoidance in daily life by decreasing family accommodation. Note that both goals are focused ultimately on the veteran’s outcomes and treatment success. Although participating in the BFI may enhance the family member’s wellbeing by providing useful information or an opportunity for the family member to receive empathic support, the purpose of the protocol is to augment and enhance the veteran’s individual treatment. Keeping the veteran engaged in therapy and reducing his or her overall levels of avoidance are the primary concerns of the BFI clinician.

Blended Case Example

Meghan² had been married to Bill, a veteran of the Gulf War, for 5 years. It was a second marriage for both parties. Bill had agreed to be seen in the PTSD clinic (on the recommendation of his VA primary care physician) after a period of job instability. His irritability and rigidity had begun to seriously impact his work performance, and for the first time in his life he felt that he was struggling to advance in his career. Meghan was very happy that Bill was in treatment; she had been frustrated by his irritability for years, but he had dismissed her every time she had suggested he “talk to someone.” However, although she knew that Bill had been deployed while he was in the Army and that there had been an accident where some men in his unit had died, she had never asked much about his military experience. He hadn’t seemed open to talking about it, and she thought it was best not to push him too much.

Session 1

At the beginning of session 1, in addition to reviewing the details of the program’s structure (length and number of sessions), we have found it necessary to briefly clarify issues of confidentiality with family members. Several family members have initially been confused about what they are “allowed” to share with the clinician; specifically, they have been under the impression that they are not permitted to describe to the clinician the nature of the veteran’s trauma or the symptoms they have observed. Therefore, we explicitly review with family members the following points: (1) the family member is permitted to share anything they choose regarding their experience or what they know of the veteran’s experience; (2) nothing that the family member shares with the clinician will be divulged to the veteran; and (3) the clinician will not be sharing anything specific regarding the veteran’s trauma, symptoms, or exact treatment activities with the family member. In cases where the family member already knows the nature of the veteran’s trauma, that information can be incorporated into the general psychoeducation or examples that are provided throughout the BFI. Again, given issues of confidentiality and trust regarding who is and is not in the room for the BFI sessions, and family members’ uncertainty with regard to the Health Insurance Portability and Accountability Act (HIPAA) rules, this discussion helps the clinician to “clear the air” from the beginning. Veterans are informed about the confidentiality procedures during the screening and consenting process, so that all parties understand what will and will not be shared with whom.

Following this brief discussion of logistics, the clinician proceeds with initial assessment and rapport-building by asking about the family member’s relationship with the veteran (e.g., how they met, how long they have known one another, whether the family member knew the veteran prior to the trauma). Family members who knew the veteran both before and after the trauma may feel more distress or confusion regarding the PTSD symptoms, whereas those who have only known the veteran after PTSD had already developed may feel more resigned or pessimistic about the potential for change. Furthermore, this early assessment allows the clinician to determine the overall tenor of the relationship currently. Family members who have extreme reactions to the veteran’s symptoms (e.g., hostility, emotional overinvolvement (Tarrier, Sommerfield, & Pilgrim, 1999)) are unlikely to benefit substantially from a very brief program such as the BFI, and it may be necessary to provide them with other resources, either individually or jointly with the veteran.

The clinician next assesses any current accommodation that the family member is engaging in by reviewing items endorsed on the Significant Others’ Responses to Trauma Scale (SORTS; Fredman, Vorstenbosch, Wagner, Macdonald, & Monson, 2014); family members complete the SORTS prior to the session. The clinician discusses each relevant item in detail with the family members to get a clearer picture of the exact behaviors. For example, a family member who marks Many Times in response to the SORTS item “How often did you avoid doing things, going places, or seeing people with [Veteran] that make him/her anxious or uncomfortable” might describe avoiding family gatherings or crowded restaurants. The clinician evaluates the functional impact of the accommodation, how bothered the family member is by a given type of accommodation, and whether the behavior lends itself to being gradually reduced as part of the BFI (this decision-making process is described further in Session 2, below).

Because several of the SORTS items deal with irritability or conflict (e.g., “How often did you avoid [Veteran] because of his/her irritable or angry mood?”), this portion of the session is also where the clinician engages in assessment around issues of risk, particularly intimate partner violence (IPV) and violence toward other family members. Veterans and service members have higher rates of IPV than the general population, and the presence of a PTSD diagnosis increases the risk (Marshall, Panuzio, & Taft, 2005). Therefore, while going through the SORTS the clinician will ask for details regarding the frequency and intensity of conflict, and follow up on any concerning disclosures of possible violence. Should immediate or likely risk become apparent, all other BFI activities are superseded by this information; in these cases, the clinician should follow the appropriate policies and procedures of his or her clinic and state. Concerning levels of risk have not thus far arisen during any of the BFI sessions that we have conducted. It is likely that veterans who are engaging in or at high risk for violence towards their family members would not agree to have those individuals participate in the program.

The remainder of the session is largely psychoeducational. The clinician describes the symptoms of PTSD and what maintains the disorder; specifically, the function of mental and overt avoidance, as well as the role of maladaptive cognitions. This leads into an overview of either CPT or PE (whichever is relevant to the veteran), including specifically describing treatment assignments and the rationale for these assignments. Family members are informed that trauma-focused treatment is difficult and may result in a temporary increase in symptoms, but that this is common and not an indication of an iatrogenic effect. They are told that dropout is a considerable problem for veterans engaged in trauma-focused treatment, and are encouraged to be alert to any signs that the veteran is considering terminating prematurely.

During this discussion of treatment, the clinician remains sensitive to the family member’s reactions, as building understanding of and support for the treatment rationale is one of the key goals of the BFI. In our experience family members have not typically expressed great skepticism regarding the benefit of openly discussing traumatic experiences and allowing oneself to feel the associated emotions, but such responses do happen. Making sure that family members understand that even unpleasant emotions must be experienced and, crucially, are not dangerous, is critical. Clinicians emphasize the strong base of research support for these interventions (Bisson, Roberts, Andrew, Cooper, & Lewis, 2013), and, if relevant, also vouch for their own personal experience in working with veterans, assuring family members that veterans do not “go crazy” during treatment and that issues of risk (e.g., suicidality or substance use) are closely monitored on a case-by-case basis.

Session one ends with the clinician reiterating the importance of family support for treatment, and particularly having the family member actively express that support to the veteran. This may include practical efforts, such as driving the veteran to therapy appointments, but largely will consist of emotional support and validation, such as telling the veteran how much it means to the family member that he or she is persisting in treatment or offering to go for a walk together after a difficult therapy session. The family member is strongly encouraged to talk to the veteran about the first BFI session, as a way of re-opening communication around PTSD in general.

At her first BFI session, Meghan reported that she and Bill had begun dating approximately 7 years ago, after they met at a work conference. She described their dating period as “fun” and said that she was happy when he proposed to her. However, over time she began to notice irritable behavior popping up, first directed at others and then eventually towards her as well (though she denied any physical or sexual violence). She was interested to hear the clinician say that irritability was a symptom of PTSD, since she had always thought it was “just his personality.” She described his angry outbursts largely as embarrassing and frustrating to her, since they often occurred in public. However, she did acknowledge that she frequently avoided raising topics of conflict or expressing displeasure because she didn’t want to deal with Bill’s reaction. Meghan stated that she knew little about PTSD, beyond “what everyone knows from TV.” She identified Bill as experiencing several symptoms that the clinician described, including nightmares, strong negative emotions, hypervigilance, and concentration difficulties. She was surprised to hear that self-blame and negative thoughts about the self were also potential PTSD symptoms; in her experience, Bill thought of himself as extremely competent (often maligning others as “idiots” in contrast) and seemed to have high self-esteem. The clinician was careful to note that not all symptoms of PTSD are present for all patients, but also explained that these types of feelings can be among the most sensitive and difficult for patients to share.

Meghan was interested to learn about CPT, including that the protocol consisted of a specified number of sessions and that there would be written homework involved. She said that she had difficulty imagining Bill doing assignments at home, since “It’s pretty hard to get him to follow through on anything he doesn’t want to do, and I don’t think this sounds like his sort of thing.” The clinician acknowledged that homework was often a sticking point in the treatment but asked Meghan if she could think of any way that she might support Bill to complete the worksheets. Meghan noted that they had a desk area in their bedroom but that it was cluttered and generally unused; she proposed that she could tidy up the area and present it as a private workspace for him. The clinician enthusiastically encouraged this idea, and they briefly role-played how Meghan could mention what she learned in the BFI session and her thoughts about the desk.

Session 2

Session two begins with a check-in with the family member regarding any questions or concerns that may have arisen since the last meeting. The clinician also inquires about whether the family member talked with the veteran about the BFI session or PTSD treatment more generally, and if so how the discussion went. The clinician then briefly reviews the information provided in the previous session and probes for additional questions or concerns. If the family member has experience in therapy him or herself, the clinician may ask them to compare the model of CPT/PE (e.g., homework assignments, deliberate exposure to uncomfortable emotions) to their own experiences. Again, the goal here is to leave space for the family member to raise any hesitations or misunderstandings that they may have regarding trauma-focused treatment, so that the clinician has the opportunity to provide information and reassurance. For example, we found that some family members agreed with the benefit of talking about the trauma in a therapy session but did not feel that the veteran should expose him or herself to trauma cues in daily life (e.g., by watching the news when the wars in Iraq and Afghanistan are being discussed). When this issue was raised, the clinician had the opportunity to clarify the connection between the in-session activities and more day-to-day efforts to reduce avoidance.

Next the clinician returns to the SORTS and begins to talk with the family member about the ways that accommodation may inadvertently maintain PTSD symptoms. The goal of this discussion is to identify behaviors that the family member can shift in the direction of greater functionality for the family as a whole, such as no longer changing the TV channel when stories about war come on or starting to go out to eat as a family even if the restaurant is somewhat busy. We have found that not all SORTS items make good targets given the nature of the BFI; for example, virtually all family members endorse the item “How often did you ‘bite your tongue’ or hold back from trying to discuss any relationship issues with your family member?” However, this item is probing for avoidance of anger rather than anxiety; furthermore, without the veteran present in session to discuss issues of communication and how to productively handle conflict, having the family member change this behavior unilaterally is unlikely to be successful (and could potentially be risky). Therefore, the clinician focuses on accommodation of anxiety or fear. These behaviors are framed as common, understandable, but unfortunately unhelpful responses by caring family members; the family member is assured that, now that the veteran is beginning a new course of treatment, it is an ideal time to have the family member working in concert with the goals of therapy. Some suggestions that we have proposed to family members include: not always staying within the veteran’s line of sight while grocery shopping together; planning dinner parties with other couples rather than never socializing; or alternating who drives the car when they are traveling together. We do not recommend eliminating all accommodation “cold turkey,” as this may conflict with our goal of having the veteran feel supported by the family member. Depending on the behavior and the planned changes, it may be advisable for the family member to discuss the changes ahead of time with the veteran; if this is the case, the BFI clinician helps the family member to role-play this conversation. In general, however, we err on the side of gradual changes to the family member’s behavior, given the fact that CPT and PE themselves are emotionally demanding. The goal is to support the treatment model while not overwhelming the veteran with challenges.

Following the discussion about reducing accommodation where appropriate, the session is concluded.

In Session Two, Meghan reported that she had cleaned the desk right after she returned home following Session One and had shown it to Bill that evening. She stated that he seemed somewhat surprised, but appreciative. She had asked him if he had been completing writing assignments already as part of his treatment, and he indicated that he had but hadn’t wanted her to see them because they were private. She reported that she told him, “That’s okay, you don’t have to show me although I’d be happy to see them if you wanted me to. But I just wanted you to have a spot where you can work on the writing more easily.” She told the clinician that the conversation had been brief, but she had been happy to be able to “do something for him – I’ve been telling him it’s good he’s coming here, but I was glad I could do more.”

From the assessment in Session One, the clinician knew that Meghan was engaging in a few accommodation behaviors. Some of these were clearly aimed at reducing or preventing anger, such as when she did not bring him to important work events because she worried he would “make a scene” and embarrass her professionally. However, others appeared to be focused on reducing his anxiety, such as never leaving his sight while they were out in public (to the extent that she would not go into a different aisle of the grocery store). In these circumstances Bill would say to Meghan, “Something terrible can happen in an instant – I need to be around to protect you, since I’m more alert to danger and have the training to deal with emergencies.” Meghan told the clinician that this attitude felt mostly sweet to her, but that it was occasionally irritating or even insulting. Nevertheless, she almost always went along with it since overall it did not cause much trouble for her. The clinician gently explained that this type of “protective” behavior was actually a manifestation of Bill’s PTSD, and that always having her close to him was reinforcing his inaccurate appraisals of risk. Meghan readily agreed that the risk of anything dangerous happening in these situations was very low, and she was happy to discuss ways that she could slowly introduce more physical distance during their outings. She and the clinician thought through a number of situations, beginning with lower stress places such as the grocery store and also considering places that might be more anxiety-provoking for Bill like a movie theater. Meghan practiced saying a brief script to the clinician that covered the main points she would want to convey to Bill (“Bill, now that you’re doing all this work in treatment, I think it would be good if we started to practice me sometimes going out of your line of sight briefly. It could help you to see that nothing bad happens. Could we try that today at the store, just for a minute or two?”)

Initial responses to the BFI among veterans and family members

In order to assess preliminary feasibility and acceptability of the BFI for PTSD, we present responses from four dyads. All portions of this study were approved by the VA Boston Healthcare System’s Institutional Review Board, and informed consent was obtained for all participants.

Participants

We recruited dyads consisting of a veteran and an adult family member. Veterans were referred by their individual clinicians once it had been determined that they were planning to begin treatment with CPT or PE. A total of five veterans were screened for inclusion in the study; one declined to participate because he did not want to have any family members involved in his treatment, resulting in 4 dyads (N = 8) in the final sample. In order to be eligible for the study, veterans needed to meet DSM-5 criteria for PTSD (as determined by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013)), be at least 18 years of age, have an eligible family member that they were willing to allow to participate, and be beginning a course of CPT or PE. Exclusion criteria for veterans were imminent suicidality or the presence of moderate or severe substance use disorder, psychosis or history of psychosis, current unstable bipolar disorder, or organic mental disorder, as determined by the Structured Clinical Interview for DSM-5 – Research version (SCID-5-RV; First, Williams, Karg, & Spitzer, 2015). Veterans were also prohibited from participating if they were currently engaged in couples or family therapy with the prospective family member. Veterans were all male, with an average age of 48.25 (SD = 26.04, range 25–83). Service eras represented were Korea (1), Gulf War (1), and post-9/11 (2). All veterans identified as Caucasian non-Hispanic. Average baseline CAPS-5 score was 37.25 (SD = 8.46); this average is well above the score of 26 which is suggestive of a PTSD diagnosis (Weathers et al., 2018), indicating that at baseline these veterans had symptoms of moderate severity.

Veterans were asked to identify a family member (including a spouse/significant other, parent, adult child, sibling, or other) that they would like to participate in the study. Veterans first discussed the study briefly with their family member, and subsequently the research team contacted the family members to further describe the study. All family members who were approached agreed to take part in the study. In order to be eligible to participate, family members needed to be at least 18 years of age and live with or have regular contact with the veteran. Family members were not eligible to participate if they met current diagnostic criteria for PTSD (as determined by the SCID-5-RV); additional exclusion criteria for family members were identical to those for veterans. All family member participants were spouses or romantic partners of the veterans. Family members were all female, with an average age of 46.75 (SD = 25.81, range 26–82). All family members identified as Caucasian non-Hispanic.

Procedures

Family members and veterans were consented and enrolled separately. At baseline participants completed diagnostic measures and a qualitative interview. Following the baseline assessment, family members attended the two BFI sessions. Veterans proceeded with their individual trauma-focused treatment; two of the veterans received PE and two received CPT. The first author conducted all of the BFI sessions; as described above, she was not the individual therapist for any of the veterans. For three of the family members, the BFI was conducted in person; for the fourth family member, the BFI sessions were completed by phone due to childcare responsibilities and distance. Six weeks after the first BFI session, a post-BFI qualitative interview was conducted individually with veterans and family members. Veterans were also administered a follow-up CAPS-5 at 6, 12, and 16 weeks post-baseline.

Interviews and Analysis

Interviews were conducted on an individual basis by the first author. A semi-structured, open-ended interview guide was used, and all interviews were audio-recorded and later transcribed. All transcripts were double-coded independently by the first and second authors. The software program Nvivo (v.11, QSR International Pty Ltd) was used for data management. We used an inductive approach to identify themes, developing the codebook iteratively as we proceeded through the analysis and modeling our analytic approach on previous studies which used grounded theory (Charmaz, 2014). A number of deductive codes were also identified prior to beginning the analysis, providing a framework that integrated a priori themes of interest with emergent themes (Bradley, Curry, & Devers, 2007). Segments of text ranging from one sentence to a short paragraph were assigned to relevant codes. Inter-rater reliability across all codes was high (kappa for veteran interviews = .92; for family member interviews = .85).

Preliminary Acceptability Data from Veterans and Family Members

Baseline interview themes

Baseline interviews focused on the veteran’s current symptoms and functioning, as well as their decision to seek trauma-focused therapy and the decision to have the family member participate in the BFI. Veterans’ feelings towards their individual CPT/PE treatment were not explored during the interview; other authors have reported qualitative data on this topic (see Hundt et al. 2015; 2017; 2018). Some themes that emerged were as follows: (see Table 1 for illustrative quotes):

Table 1.

Illustrative quotes from family members and veterans at baseline

	Family members	Veterans
Knowledge of PTSD	“Oh, I guess very little. I kind of know the shell of it probably. I know what everybody knows, but I wouldn’t say it’s deep….I really haven’t [sought out information about it], no. Which seems like an oversight now that we’re talking about it.”	“She doesn’t understand trauma. She probably thinks she does….She knows what caused it, and I kind of talked to her about it once in a while. But if you haven’t been through it you don’t know what it is.”
Expectations of individual treatment	“I’m assuming just kind of talking about the triggering event and talking about you know…the parts of his behavior that may actually be coming from or consequences of that event.” “I know that a lot of his sessions revolve around um, desensitizing him to the experiences that he had.”	None
Disclosure about trauma events	“I think [talking about the trauma] will be good for him. Good to get that out, maybe he’s telling Dr. X things he’s never told me. I don’t know. But that’s good, I think. It’s good…I don’t think it can hurt him at all.”	“She has a general understanding of some of the events. But as far as, you know, details, no she doesn’t have any of those.”
Goals and motivations for participation in the BFI	“[The veteran] really really wanted me to do this [family program]. He brought it up a couple of times and I said ‘No, I have [family obligations] and everything.’ He brought it up a second time and I was just like ‘Yeah, I’ll think about it’ and then the third time he actually brought a phone number. My husband…he’ll throw things out there and it’s just out there and I’m like ‘Yeah whatever.’ This is something he came back to numerous times, I knew it meant something to him. And because he was coming to me, instead of me engaging him, I figured ‘If it means that much to him, I’ll go ahead and do it.’” “[I want to learn] what I should say, what I should do or how far to push or how far not to. If the stuff that I’m doing is the right thing to be doing….How to deal with it when he has flare ups….” “And I think from his perspective, you know, talking for him now, which I shouldn’t do, but I think he would really like for me to better understand PTSD and kind of understand some of his behaviors that maybe I don’t associate with PTSD that might be linked and so I think he’s hoping that I’ll be more aware.”	“I think it’s just [for her] to have more of an understanding of the numbness. And how it impacts the way I interact with people… I guess just maybe more patience with the process.” “[I want her] to accept what I have. To accept what I have.” “I’m pretty poor at communicating about PTSD and anything like that. And I’m told that I’m a pretty emotionless person. So I figured if we both entered this study then maybe she could get more insight as far as things that I’ve gone through, or people like me have gone through, and maybe different ways to approach different scenarios.” “I mean just because I have a diagnosis of PTSD doesn’t necessarily mean I know enough about it to convey that to my wife, so….”
Potential negative outcomes from the BFI	“I feel like in all honesty it could only get better. I don’t think it would be a negative affect at all. Because it would just be stagnant, it would just be what it is anyways. So yeah I feel like this only can go well I guess.” “My only concern is that me and my husband have gone to couple therapy. It didn’t work out well for us. I mean he felt, he didn’t feel validated or heard on a lot of the appointments. And the appointments that he did feel validated or heard, I didn’t feel validated or heard. So every time we left couple therapy we never felt better. I think it wasn’t very productive in the sense that we really did try and we went for a couple of months and it was not productive, and so because of that I’m afraid that if I tried to put myself in any of his therapy he’ll take a step back from it. And I really need him to be involved in it.”	“She could come to realize that, you know, the man she fell in love with and married isn’t me anymore. Like, I constantly go back and think about how damaged I am now. So she could go through this study and realize just how damaged I really am and cut her losses, save face. Try and move on, find somebody else, somebody better I guess. I don’t know how realistic that fear is but….”

Knowledge of PTSD.

Most family members reported having minimal knowledge about PTSD. What they knew was largely gleaned from popular culture, and all family members denied ever having researched PTSD or specifically sought information about treatment. The veterans reported that from their perspective, their family members did not know (and could not know) what the experience of PTSD was truly like.

Expectations of treatment.

At baseline family members were uncertain regarding the specific techniques and goals of trauma-focused treatment. All reported expecting that there would be some discussion of the traumatic event itself. One felt that the treatment would likely focus on “desensitizing” the veteran to the trauma. Again, no family member reported having researched anything regarding common PTSD treatments, and no family member had been involved in the veteran’s mental health care treatment previously.

Disclosure about traumatic events.

All family members reported that they knew at least a small amount about the nature of the veteran’s trauma(s), although the level of knowledge and ongoing discussion varied. In some cases the trauma disclosure had come in the context of a crisis, such as the veteran having suicidal ideation or experiencing serious physical symptoms related to stress. A family member who learned about the veteran’s trauma many years after the fact noted that he seemed happier and more open since he disclosed. In general family members anticipated that the veterans would find talking about their traumas in treatment difficult, but that they would benefit from having done so. Most of the veterans stated that their family members knew the basics about the traumatic event(s), but only one had discussed it in detail with his partner, and even in that case the most graphic details had been omitted.

Goals and motivations for participation in the BFI.

All family members mentioned wanting to gain skills and knowledge so that they could better support (or stop themselves from inadvertently harming) the veteran. Many also spoke of participating in order to more actively demonstrate their caring or commitment to the veteran. Agreeing to enroll in the study and attend the BFI sessions was a concrete way for them to show that they were on the veteran’s side. All veterans reported wanting their family members to “understand” them and their experience of PTSD. This “understanding” largely seemed to encompass sympathy, patience, and acceptance of symptoms and behaviors (e.g., hypervigilance, restricted affect). Veterans also wanted help in communicating about PTSD more generally, because they felt unequipped to describe their treatment or experiences clearly.

Potential negative outcomes from the BFI.

All family members expressed optimism about the BFI. One family member noted that she and the veteran had had a bad experience in couples’ therapy in the past, and that she wanted to be sure that her participating in the BFI did not cause her husband to become disengaged from his individual treatment. Veterans were also generally optimistic regarding the BFI; one veteran noted a concern that some family members might develop a false sense of expertise about PTSD following the intervention. Another veteran worried that his wife might find out more about how “damaged” he was by his trauma and leave him.

Exploratory Treatment Outcomes

All family members completed both BFI sessions; there were no cancellations or no-shows, suggesting good feasibility and acceptability of the intervention. Regarding the veterans’ individual treatment, three of the four veterans completed CPT/PE as planned; the fourth veteran was unable to finish the protocol due to medical issues, and he and his family member were also unable to participate in the follow-up interviews and assessments due to these health complications. The average decrease in CAPS-5 total score for veterans over the 16 weeks was 11.33 points (SD = 13.01).

Follow-up Interview Themes

Follow-up interviews focused on any changes that had been observed by veterans and family members following the BFI sessions. Participants were also asked about the extent to which they had discussed the BFI or CPT/PE sessions with their partner, and about their opinion of certain possible modifications to the BFI. The following themes emerged (see Table 2 for illustrative quotes):

Table 2.

Illustrative quotes from family members and veterans at follow-up

	Family members	Veterans
Changes following BFI	“I would say I’m maybe a little bit more aware as I react and respond to certain things. I’m probably more aware of where it might be coming from or what it’s rooted it in.” “[S]ometimes he’ll be like ‘Well no, I just need to do this, can you give me space? Like I don’t want you near me when I’m doing this homework.’ And whereas before I would kind of be like, ‘Well what the heck, I’m just trying to help, why don’t you want me near you?’ ….not making it about me, but just feeling bad that he doesn’t want me around. And now I kind of get it…so I back off about that. But he’s also responding better to when I ask him a little bit about the homework. I’ll be like ‘So what’s it about?’ and he still won’t say exactly but he’ll say ‘Oh well, it’s just about [the trauma],’ or ‘It’s about [my deployment]’ and that’s it. But it’s not so snappy and mean.” “[The BFI] does help me to kind of like put A, B, and C together, connect them a little bit easier and to be mindful of it too. So instead of just being like ‘It’s something that he has to deal with,’ which it is, it is something he does have to deal with, and yes retroactively it affects our lives together. But it’s also something that I can help him deal with and I think this has helped, reminded me of that, and given me some more tools.”	“[W]hen she came back from her first appointment she was more open and understanding to…asking, like, how my days were going. Prior to her coming in to the [BFI] program for the first time I would come home and she would say ‘Oh, how was work?’ I don’t like bringing work home with me so I would just say, ‘Work’s fine,’ wouldn’t go into detail about it. But then I realized after she had made contact with the program and had a better understanding of everything, she started asking how I was physically and emotionally and things like that, which was a little strange at first but it was good for the most part.” “I was [telling her more about how things were going for me emotionally]. You know, what angered me. But I mean, as any vet will tell you, anger is a pretty easy one, you know? What threw me off was when she asked me, you know…how did she word it? What I was fearful of. And I mean, me personally…you ask “Well, what are you afraid of?” and I’m just gonna shut that whole topic down or attack it with aggressiveness. But it was the way that she worded it where…I found it easier to express emotional fear or what have you.” “It was nice to know I had somebody there.”
Disclosure (about treatment or trauma)	“So before [the BFI sessions]…I didn’t even know that he had homework, if that’s what you want to call it. So I asked about that [after the BFI] and he said ‘Yeah we have a few exercises’ but I mean, he doesn’t really share too much….” “He just has talked a little bit about some of the activities that he’s doing, and he will usually give me a sense after the session about whether it was difficult or whether it was sort of a relatively easy session. He talks a lot about, in those difficult sessions, how he kind of loses track of time and will just kind of get lost in what’s going on.”	“Probably [having her participate in the BFI] made it easier for me to talk about. Especially the PE stuff per se. Because she at least had a foundation to understand it. And I didn’t necessarily have to give her as much detail about the process because she kind of already had an understanding of what the process was. So I could use the word ‘imaginal’ and she already knew what imaginal meant, right?” “[We talked about the BFI sessions] a little bit. We never got into a lot of detail and she hasn’t shared a lot. But I don’t ask probing questions, and I don’t do that with my kids either. If they want to tell me something they will. Otherwise…I’ll open the question with, you know, ‘How was it or how did it go?’ and if you say nothing then that’s how it went. I’m not going to go beyond that.”
Environment of BFI	“I think that I definitely learned the question of what actually is PTSD, because…I mean, people obviously know what it is, um the meaning of it, like what PTSD stands for, but it’s also hard to actually understand how it really affects someone and like, all the reading I’ve done online, that only gets you so far. So it works a lot better when you’re talking to with someone who is from the same place that the person who has PTSD is going to as well, because they know them better….So I think it’s just a better communication process dealing with someone that’s in the same organization [where the veteran is being treated].”	“Well there’s certainly the trust factor you know, coming from a doctor….It’s the professionalism, the atmosphere, that all of this provides. Which is good.” “She was fearful [when I started treatment at the VA], not fearful of like ‘Oh my goodness, what’s going to happen, are they going to hook him up to gadgets and electrocute him?’ But she was just worried…that I was getting sub-quality care when I wasn’t. So by her coming in here and doing this, I think that that definitely relieved some of the anxiety for her.”
Interpersonal effects of PTSD	None	“I would say that if like a veteran is going to, you know, finally come in here and ask for help, right? I would say that it would be more beneficial…to push that veteran more towards this [family] program and do this as a preemptive step….You would have to explain it, like, ‘Listen, I know you’re feeling X, Y and Z, and we respect that you want to get the treatment and we’re going to give it to you, but, you know, if you were a single guy we’d get you started next week. But you’re not, you know, you’re a married man or you have a girlfriend or you’re in a relationship….’ I would try to push them to do this sort of [family] thing first because it really is a team effort and everybody’s affected by this.” “If the work is just being done by the veteran…it’s not going to work, it’s not. And you know, maybe in a perfect world there’s a single guy and all his problems are just problems with himself, but I truly don’t believe that they are, you know? I think PTSD affects everyone. We’ve even joked about it. She’s like… ‘I need something, I think I have PTSD or something from you.’ It’s a joke but, like, yeah it’s kind of true.”
Utility of a possible joint session with veteran present	“The question just sort of from a method perspective that I wonder about is whether or not a joint session might have been helpful? You know certainly not to invade his privacy in any way, but just to get a little bit more insight beyond what he tells me afterward. To get a little bit more direct insight about what’s going on and sort of how, how it’s progressing and how he’s feeling.” “Nooo. I think that, it goes back to, my husband needs to know he has a safe place to go, that he can say whatever he’s going to say and it’s never going to come back to me or anybody else. My husband needs to be able to go and vocalize that he hates my guts that day, or he, he doesn’t want to come home to his friggin’ family, and not have to worry about me emotionally having to hear that and any sort of fallout from it. I think that is a huge thing for men in general, I hate to, you know, generalize, but I think that’s a huge thing for men. That they really do need to have their safe place to be able to open up because it’s hard for them to do that. So I think that the fact that we were separate [for our sessions] was really good.”	“Yeah, that would have been interesting to do that. I don’t know, I’m 50/50….I don’t know whether it would be good or bad.” “It just gives you a chance to…maybe share some specifics. In a, you know, let’s call it a refereed setting. Where the professional is there to make sure the…certain groundwork is covered, right? If there’s 10 things that need to be talked about, that all 10 things get checked.”
Attitude towards a possible group BFI	“I don’t know. I don’t think so… I feel like it could, well, number one, [the veteran]’s very quirky and strange on his own so I feel like I don’t know if anyone would be very similar or not…and I don’t know if I would be as open to say a lot of the stuff in front of people that I didn’t know….Yeah, especially because he doesn’t like to share his business a lot, and I would almost feel like I was talking about his personal issues like behind his back almost.” “Um, preferred it? No. Would I also have participated and be interested in it, of course! I would love to meet other women that who have gone through what I’ve gone through.”	None

Changes following the BFI.

Family members reported that, following the BFI, they were more alert to the ways that veterans’ emotions and behaviors might be influenced by their PTSD. They were able to take irritability less personally and be more empathic in times when the veteran was stressed. The veterans noted more emotional openness and connection between the family members and themselves, and a sense of increased support.

Disclosure.

Most family members stated that they still did not talk in detail about the CPT/PE sessions with the veterans. They reported that the veterans continued to be fairly circumspect in terms of sharing details of treatment. One veteran did report talking in detail with his partner about his individual treatment sessions; he reported that knowing his partner had received some preliminary information about the treatment made it easier to broach the topic. Two of the three dyads who completed follow-up interviews had not discussed the BFI sessions at all; the third had talked about it only briefly.

Environment of the BFI.

Some family members mentioned that they particularly enjoyed meeting with a clinician who worked in the same clinic where their partner was seen, and who was familiar with their partner’s treatment team. One mentioned that even being able to physically come to the VA was a benefit to her, since it allowed her to more clearly imagine what her partner was experiencing. One veteran noted that his partner had been concerned about the quality of his care at the VA, given bad publicity that the agency has received in recent years, and that coming to the facility and meeting the team in person alleviated some of her worry.

Interpersonal effects of PTSD.

There was agreement among the veterans that PTSD affects more than just one person, and therefore that having the option of a family program is important. One veteran strongly felt that all partnered veterans should be required to have a spouse or significant other involved in their care prior to beginning individual treatment.

Utility of a possible joint session with the veteran present.

Family members were divided regarding the benefits of a joint session. One felt that she would have liked the option and that it would have given her more insight into the veteran’s experience, while another was strongly opposed. Veterans had some hesitation about a joint BFI session, but also saw the potential for it to be positive. One felt that the presence of a clinician could help to “referee” or guide the discussion.

Attitudes towards a possible group version of the BFI.

None of the family members reported that they would have preferred a group version of the BFI, and two of the three stated that they would not have been willing to attend in a group format. They had concerns about privacy and also wondered whether the experiences of other family members would be too different from their own to feel relevant.

Discussion

This paper introduced a novel, brief family protocol that is designed to complement CPT or PE delivered in usual care in the VA. We present outcomes that speak to the preliminary feasibility (operationalized by rates of recruitment and retention) and acceptability (as indicated by qualitative feedback from family members and veterans). These initial results suggest that the program was feasible, with good rates of both recruitment success (80% of veterans and 100% of family members approached) and completion (100% of BFI sessions were completed by family members). Qualitative feedback shows that this small sample of family members and veterans were satisfied with the intervention as it was delivered, and also provide some perspective on the utility of possible modifications.

The BFI was designed to provide psychoeducation and elements of brief skills-building to family members, leading to downstream changes in their supportive and accommodating behaviors (increasing and decreasing, respectively). From the perspective of this group of veterans and family members, it appears that the primary impact of the BFI was to foster greater support, acceptance, and connection. This increased harmony is in line with the pre-intervention goals that both veterans and family members identified; although participants had also described wanting help with practical skills (family members) and communicating the details of PTSD and treatment (veterans), following the intervention they were much more likely to highlight the impact of the program on their emotional connection. It is well established that the families of patients with PTSD experience high levels of discord (Jordan et al., 1992; Riggs, Bryne, Weathers, & Litz, 1998; Solomon et al., 1992), and it appears that having family members attend the BFI sessions improved these dyads’ daily interactions, irrespective of the program’s content and focus. Future studies might incorporate a more detailed analysis of the quality of dyads’ interactions prior to and following the intervention, perhaps by using ecological momentary assessment (Ebner-Priemer, Eid, Stabenow, Kleindienst, & Trull, 2009) or an in-lab conflict discussion task.

Family members wanted a window into the veterans’ experience, one that they had not previously had during other mental health treatment episodes due to the veterans’ reluctance (or inability) to communicate in much detail about trauma or treatment. However, family members were uncertain about the possibility of sharing their struggles more broadly in a group BFI setting. Finally, as was evident during the post-interviews, veterans and family members were limited in the amount of detail that they shared with one another about either CPT/PE or the BFI sessions. It is likely that finding ways to increase communication about the BFI and/or the veteran’s individual treatment and symptoms would enhance dyads’ relationship satisfaction. Campbell and Renshaw (2013) found that service members’ levels of disclosure mediated the relationship between emotional numbing and relationship satisfaction. Lack of disclosure negatively impacts intimacy and connection (e.g., Bradford, Feeney, & Campbell, 2002; Dekel, Goldblatt, Kiedar, Solomon, & Polliack, 2005). More effectively encouraging family members to discuss the BFI with veterans, perhaps via a “homework assignment” following session one, might facilitate more disclosure from the veteran about his or her treatment experience as time went on. Nonetheless, even without increases in disclosure, veterans and family members expressed appreciation for the BFI and noted positive changes in their relationships.

The BFI protocol that was developed is essentially an abbreviated form of PTSD-specific family psychoeducation (Lucksted, McFarlane, Downing, & Dixon, 2012). Despite the intervention’s brevity and simplicity, responses from the family members and veterans who participated were strongly positive. There was a mixed response to our questions regarding some possible additions or adaptations to the protocol, such as delivering the BFI to groups of family members simultaneously or adding a joint session with the veteran. However, a joint session would have some of the same drawbacks as existing family-involved treatments (e.g., practical difficulties with scheduling and provider hesitancy towards couples’ treatment), and we feel that the advantages of having a very brief, simple-to-administer treatment outweigh the potential benefits of a joint session at this time.

A limitation of the BFI itself is that it does not provide for the passing of collateral information from the BFI clinician to the veteran’s individual clinician. Again, given the confidentiality concerns on all sides, we opted to arrange the sessions in a way that was completely separated from the veteran’s individual treatment. Nothing in the BFI manual prevents the individual CPT/PE clinician from having a separate visit with the family member and veteran in order to gather collateral information if they feel it is necessary. Another limitation of the protocol is its brevity; while the decision to limit the intervention to two sessions was intentional and has benefits in terms of feasibility and acceptability, it is not possible to include all of the therapeutic targets that might conceivably be useful for families. We consider the BFI to be a promising, low-cost, entry-level intervention that can hopefully be useful with a broad range of families. However, there will certainly remain an important role for more intensive protocols focused on PTSD symptoms and/or on couple and family distress more generally. These needs exist on a spectrum, and the BFI will not be indicated or sufficient in every case.

Regarding the responses presented here, a primary limitation is the fact that the first author (JTH) conducted both the BFI sessions and the qualitative interviews. This arrangement may have influenced the responses of the participants, particularly the family members. Another limitation is that all of the dyads were romantic couples. Although the protocol is designed to be broad enough to incorporate a range of family relationships, we do anticipate that most participants will be spouses/partners. Many veterans seeking PTSD treatment are in a serious romantic relationship (Fontana, Rosenheck, Spencer, Gray, & DeLella, 2000), and these are naturally the people who are likely to have the most regular and close contact with the veterans. Finally, the participants were entirely Caucasian, and all dyads consisted of a male veteran and a female partner. While a majority of veterans are white males (US Department of Veteran Affairs, 2018), the dynamics of family involvement may be very different among racial/ethnic minority participants, when a female veteran is the patient, or among LGBT couples.

Conclusions

The experience of conducting these initial BFI sessions provided important information to guide the continued development of the protocol. The responses to our initial interviews indicate that a family-focused, adjunctive intervention to trauma-focused individual therapy may be an appealing and feasible option for veterans and family members. Next steps include a randomized controlled trial comparing the BFI to a no-BFI control condition among a slightly larger group of dyads, where veterans in both conditions receive CPT or PE as usual. This study will include quantitative assessments of social support, relationship functioning, and avoidance, to expand our understanding of the BFI’s potential effects. Furthermore, we intend to continue to assess the acceptability of the protocol among usual-care clinicians in VA, to help maximize the potential for future dissemination and implementation throughout the system. Finally, we plan to explore which family member, veteran, and relationship characteristics are most associated with positive outcomes for family involvement, in order to better target such treatments.