Cognitive–behavioural conjoint therapy versus prolonged exposure for PTSD in military service members and veterans: results and lessons from a randomized controlled trial

ABSTRACT

Background:

Military personnel and veterans are at heightened risk for exposure to traumatic events and posttraumatic stress disorder (PTSD), as well as intimate relationship problems associated with PTSD.

Objective:

The purpose of this study was to evaluate the relative efficacy of CBCT and PE in improving intimate relationship functioning in active duty military personnel or veterans and their intimate partners; both conditions were hypothesized to significantly improve PTSD. Method: In this study, 32 military service members or veterans with PTSD and their intimate partners were randomized to receive either Cognitive–Behavioral Conjoint Therapy for PTSD (n = 15; CBCT; [Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Harnessing the healing power of relationships. Guilford]), a trauma-focused couple therapy, or Prolonged Exposure (n = 17; PE; [Foa, E. B., Hembree, E. A., Dancu, C. V., Peterson, A. L., Cigrang, J. A., & Riggs, D. S. (2008). Prolonged exposure treatment for combat-related stress disorders – provider’s treatment manual [unpublished]. Department of Psychiatry, University of Pennsylvania]), a front-line evidence-based individual treatment for PTSD.

Results:

There were significant challenges with recruitment and a significant difference in dropout from treatment for the two therapies (65% for PE; 27% for CBCT). Treatment dropout was differentially related to pre-treatment relationship functioning; those with below average relationship functioning had higher dropout in PE compared with CBCT, whereas those with above average relationship functioning did not show differential dropout. In general, CBCT led to relational improvements, but this was not consistently found in PE. Clinician- and self-reported PTSD symptoms improved with both treatments.

Conclusions:

This study is the first to test a couple or family therapy against a well-established, front-line recommended treatment for PTSD, with expected superiority of CBCT over PE on relationship outcomes. Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout on trial analyses are discussed. This trial provides further support for the efficacy of CBCT in the treatment of PTSD and enhancement of intimate relationships.

HIGHLIGHTS

• Differential dropout from trial of couple versus individual therapy for PTSD.

• General pattern of improvements in relationship outcomes in couple therapy for PTSD.

• PTSD symptoms improved in the individual and couple therapy for PTSD.

• Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout by condition on trial analyses are discussed.

Antecedentes: El personal militar y los veteranos están en mayor riesgo de exposición a eventos traumáticos y el trastorno de estrés postraumático (TEPT), así como también a problemas de relaciones íntimas asociadas con el TEPT.

Objetivo: El propósito de este estudio fue evaluar la eficacia relativa de la Terapia Conjunta Cognitiva-Conductual (CBCT, en su sigla en inglés) y Exposición Prolongada (PE, en su sigla en inglés) en mejorar el funcionamiento de la relación intima en el personal militar en servicio activo o los veteranos y sus parejas intimas; se hipotetizó que ambas condiciones mejorarían significativamente del TEPT.

Método: En este estudio, 32 miembros del servicio militar o veteranos con TEPT y sus parejas intimas fueron asignados de forma aleatoria para recibir ya sea CBCT para TEPT (n = 15; CBCT; Monson & Fredman, 2012), una terapia de pareja centrado en el trauma, o PE (n = 17; PE; Foa et al., 2008), un tratamiento individual basado en la evidencia de primera línea para el TEPT.

Resultados: Hubo desafíos significativos con el reclutamiento y una diferencia significativa en el abandono al tratamiento para las dos terapias (65% para PE; 27% para CBCT). El abandono del tratamiento se relacionó diferencialmente con el funcionamiento de la relación antes del tratamiento; aquellos que tenían un funcionamiento de la relación bajo el promedio tuvieron un abandono más alto en PE comparado con CBCT, mientras que aquellos con un funcionamiento sobre el promedio no mostraron abandono diferencial. En general, CBCT resultó en mejoras relacionales, pero esto no fue encontrado en PE. Los síntomas TEPT clínicos y de autoinforme mejoraron en ambos tratamientos.

Conclusiones: Este estudio es el primero en evaluar la terapia de parejas o familias contra un tratamiento recomendado de primera línea, bien establecido para el tratamiento del TEPT, con superioridad esperada del CBCT por sobre el PE en los resultados de las relaciones. Se discutieron las lecciones aprendidas en el diseño de ensayos, incluyendo consideraciones de equilibrio, y los efectos del abandono diferencial en los análisis de ensayos. Este ensayo provee mayor apoyo para la eficacia del CBCT en el tratamiento del TEPT y la mejora de las relaciones íntimas.

KEYWORDS:

• Military
• PTSD
• treatment
• prolonged exposure
• cognitive–behavioural conjoint therapy
• couple therapy
• intimate relationships

PALABRAS CLAVE:

• Militar
• TEPT
• tratamiento
• exposición prolongada
• terapia conjunta cognitiva conductual
• terapias de pareja
• relaciones íntimas

Acknowledgement

We greatly appreciate the participation of the participants in this study. The views expressed herein are solely those of the authors and do not reflect an endorsement by or the official policy or position of Brooke Army Medical Center, Carl R. Darnall Army Medical Center, the US Army Medical Department, the Defense Health Agency, the US Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, the Department of Defense, the Department of Veterans Affairs, or the US Government.

Disclosure statement

Dr Candice Monson receives book royalties and speaking fees related to the treatment manual of cognitive-behavioral conjoint therapy for PTSD and other trauma-related topics. She also owns equity in Nellie Health, Inc. Dr Anne Wagner has received payment as a consultant from Lykos Therapeutics, the California Institute for Integral Studies, and the Integrative Psychiatry Institute. She is the founder of Remedy.

Data availability statement

The data from this study are maintained at the University of Texas Health Science Center at San Antonio in the STRONG STAR Repository. Requests for access to the data as well as for materials and the analysis code also can be emailed to [email protected].

Notes

1 An assessment at 12-months posttreatment was also included, but only four couples completed this assessment, so this time point was excluded from analyses.

2 To create the time variable during treatment, the session number was divided by the total number of sessions for the therapy so that 0 = baseline and 1 = posttreatment in both conditions.

Additional information

Funding

Funding for this work was made possible by the US Department of Defense through the US Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, Psychological Health and Traumatic Brain Injury Research Program awards [W81XWH-08-02-109] (Alan Peterson), [W81XWH-08-02-0114] (Brett Litz), and [W81XWH-08-02-0115] (Candice Monson). Role of the funding source: The grant sponsor played no role in study design; the collection, analysis, and interpretation of data; the writing of this paper; or the decision to submit this paper for publication.