Cognitive-Behavioral Conjoint Therapy for PTSD: Initial Results from a Community Sample Candice M. Monson, Ph.D. Steffany J. Fredman, Ph.D. Susan P. Stevens, Psy.D. Paula P. Schnurr, Ph.D. Patricia A. Resick, Ph.D. Kathryn C. Adair Helen Z. MacDonald
Top 5 Reasons for Conjoint Therapy for PTSD 1. Get 3 results from 1 therapy based on: controlled trials of generic behavioral couple/family therapy for PTSD (e.g., Glynn et al., 1999) open trial of disorder-specific CBCT for PTSD (Monson et al., 2004; 2005) 2. Negative family environment associated with worse outcome in individual treatment (e.g., Tarrier et al., 1999) 3. Existing therapies don t improve intimate relationship functioning (Monson et al., 2006; Galovski et al., 2005) 4. Drop out and Non-/partial response to existing evidencebased therapies (Bradley et al., 2005; Hembree et al., 2003) 5. PTSD highly associated with relationship problems (e.g., Whisman, 2000; Nelson Goff et al., 2006) Functional problems get and keep people in therapy
Overview of CBCT for PTSD Disorder-specific intervention Trauma-focused, but not imaginal exposure-based 15 sessions, manualized 1.25-hour sessions Customary inclusion/exclusion criteria for PTSDidentified partner Partner not diagnosed with PTSD Exclusionary criteria specific to relationship u Current severe violence u Minimal commitment 3 The treatment is trauma-focused but not exposure based that is, we discuss events in enough detail for everyone to have shared understanding of what happened but not get into nitty gritty, gory details as in more traditional exposure-based therapies
Cognitive-Behavioral Conjoint Therapy for PTSD Stage 3 Dyadic Cognitive Restructuring Stage 2 Relationship Enhancement Undermining Avoidance Stage 1 Introduction, Psychoeducation, Safety Building Monson & Fredman, in press RESUME Living
Pilot Sample Characteristics Couple # Trauma Type Gender of IP Race/ Ethnicity Sexual Diversity 1 Harassment Female White Same sex 2 OIF Combat Male White Heterosexual 3 OIF Combat Male White Heterosexual 4 CSA Female African- American Heterosexual 5 OIF Combat Male White Heterosexual 6 CSA Female White Same sex 7 CSA Male White* Heterosexual R34 MH076813 (PI: Candice Monson, Ph.D.) 5 7 couples enrolled in pilot study. Pretty diverse with respect to: index trauma (3 combat related to Iraq war, 3 CSA, & 1 Harassment that involved perceived threat to physical integrity) Roughly balanced between men and women for IP Sexually diverse (2 female same sex couples) Age (25-60) SES (living on $4000/year SSDI in public housing with bed bugs to those working in business earning > $100,000) Five of 7 had at least one partner who scored in clinically distressed range, according to DAS
Measures u Clinician Administered PTSD Scale (CAPS) u PTSD Checklist (PCL) u Patient u Partner u Dyadic Adjustment Scale (DAS) u Beck Depression Inventory (BDI) 6 CAPS clinician interview used to make DSM-IV dx of PTSD PCL-I & PCL-C: patient and partner each rate pt s symptoms using self-report measure BDI patient and partner each rate own symptoms of depression DAS self-report measure for each to rate relationship adjustment
Overall PTSD Symptoms 80.00 60.00 40.00 20.00 57.0 d = 1.52 *** 43.8 d = 1.32 * 46.0 d = 1.69 * Pre-tx Vietnam Vete Post-tx Vietnam Ve Pre-tx Post-tx 3-D Column 5 3-D Column 6 PTSD Symptom Severity 0 Clinician Interview Self-report Partner-report ***p <.001. *p <.05. Measure 7 Monson, C. M., Schnurr, P. P., Guthrie, K. A., & Stevens, S. P. (2004). Cognitive-behavioral couple's treatment for posttraumatic stress disorder: Initial findings. Journal of Traumatic Stress, 17, 341-344.
PTSD Symptom Clusters 20.00 15.00 10.00 5.00 16.67 d =.90 9.00 + d = 13.67 1.70 * d =.99 17.67 d = 1.92 + ** Pre-tx Vietnam Post-tx Vietnam Pre-tx Post-tx 3-D Column 5 3-D Column 6 PTSD Symptom Severity 0 Re-exp Avoidance Numbing Hyperarousal + p =.07. *p <.05. **p <.01. CAPS Subscale 8 Monson, C. M., Schnurr, P. P., Guthrie, K. A., & Stevens, S. P. (2004). Cognitive-behavioral couple's treatment for posttraumatic stress disorder: Initial findings. Journal of Traumatic Stress, 17, 341-344.
Relationship Satisfaction 115.00 111.25 107.50 103.75 100.00 d =.71 + 102.22 104.32 d = 1.41 * Dyadic Adjustment Total Score Pre-tx Vietnam Post-tx Vietnam Pre-tx Post-tx 3-D Column 5 3-D Column 6 PTSD Client Partner *p <.05. +p =.07 Source 9 Monson, C. M., Schnurr, P. P., Guthrie, K. A., & Stevens, S. P. (2004). Cognitive-behavioral couple's treatment for posttraumatic stress disorder: Initial findings. Journal of Traumatic Stress, 17, 341-344.
Comorbid Depression 25.00 18.75 12.50 6.25 0 12.83 PTSD Client d =.80 4.09 Partner d =.06 Beck Depression Inventory Total Scores Pre-tx Vietnam Post-tx Vietnam Pre-tx Post-tx 3-D Column 5 3-D Column 6 Source 10 Monson, C. M., Schnurr, P. P., Guthrie, K. A., & Stevens, S. P. (2004). Cognitive-behavioral couple's treatment for posttraumatic stress disorder: Initial findings. Journal of Traumatic Stress, 17, 341-344.
Future Directions Head-to-head trial Dually traumatized/ptsd couples Relationship satisfaction as moderator Conjoint versus couple Need cognitive stage? 11
Acknowledgments u Amy Brown-Bowers, B.A. u Karen Guthrie, M.S.W. u Alex Macdonald, Ph.D. u Timothy J. O Farrell, Ph.D. u Valerie Orstenbasch, M.A. u Suzanne L. Pineles, Ph.D. u Jennifer L. Price, Ph.D. 12 u Phillipe Schneider
Candice M. Monson, Ph.D. Associate Professor & Director of Clinical Training, Ryerson University Affiliate, VA National Center for PTSD, Women s Health Sciences Division 350 Victoria Street Toronto, ON M5B 2K3 Candice.Monson@Psych.Ryerson.ca 416.979.5000, ext. 6209