Q: Can this therapy be done if the partners have separated?
Q: Can you use this therapy if the couple reports aggression?
Q: How do you handle situations in which improving the relationship and improving PTSD seem at odds? For example, say the partner without PTSD does not want the Identified Patient (IP) to conduct in-vivo approach assignments, maybe because of the partner’s own worry or efforts at control, and this causes conflicts within the relationship.
Q: Does the IP have to share details of the traumatic event?
Q: Is hearing details of the traumatic event potentially traumatizing to the other partner?
Q: What if she or he wants to disclose and the partner does not want to hear about the event?
Q: What if you don’t have 15 weeks to work with couples?
Q: Can you deliver the therapy to a couple if both partners have PTSD?
Q: Would you include children or other family members in the therapy?
Q: Can this therapy be done if the partners have separated?
A: CBCT for PTSD can be conducted as long as the partners can commit to work on the relationship for the duration of the therapy. If the couple indicates that they plan to terminate the relationship, then this therapy is not recommended.
Q: Can you use this therapy if the couple reports aggression?
A: Yes, but consistent with couple therapy guidelines, we use the therapy with couples who report less severe forms of intimate aggression and if neither of the partners report being afraid of the other partner. We would refer for individual treatment focused on severe aggressive behavior and would pursue a course of the therapy if the severe aggression had decreased in the relationship. We recommend that therapists do an objective assessment of aggression as part of the initial assessment with the couple.
Q: How do you handle situations in which improving the relationship and improving PTSD seem at odds? For example, say the partner without PTSD does not want the Identified Patient (IP) to conduct in-vivo approach assignments, maybe because of the partner’s own worry or efforts at control, and this causes conflicts within the relationship.
A: The first step is to identify specifically what aspects of treatment seem to be increasing conflict. Make sure the couple understands the rationale for any of the interventions that may be increasing conflict because that is the key to having couples successfully engage in the exercises and assignments. Therapists should encourage couples to use the relationship skills they learn in the therapy and the therapist will likely want to challenge stuck points that either member of the couple has that are interfering with delivery of the therapy. The partner may be reluctant to have their loved one with PTSD do things that may be upsetting and related to the trauma, which can be destabilizing, so they try to protect the person with PTSD.
The therapists should determine what the thinking is behind the partner’s reluctance to have the IP face what they fear and develop more balanced and functional thoughts for the long term. Often the partner is thinking short term (don’t upset) and may not fully grasp the long-term consequences of continuing to protect the IP from his or her distress.
Q: Does the IP have to share details of the traumatic event?
A: They would be expected to share enough details that the therapist and partner can help put the traumatic event back into the context of what was going on at the time. However, this typically involves a rendition of the event that does not involve the nitty-gritty sensory details of the event but rather a narrative of what occurred.
Q: Is hearing details of the traumatic event potentially traumatizing to the other partner?
A: The research and our clinical experience indicate that what is stressful to the partner about the IP’s traumatic event are not the events per se, but the psychopathology that has arisen as the result of those events. The risk for vicarious traumatization is also low in CBCT for PTSD because of its cognitive approach to processing the trauma.
Q: What if she or he wants to disclose and the partner does not want to hear about the event?
A: We recommend exploring what the partner’s concerns are about hearing about the event and challenge any misconceptions that partner may have. For example, the partner might believe that disclosing the trauma might make the IP worse, or that it will lead to PTSD for the person who hears about it. The therapist should explain that paradoxically, trying to avoid talking about it or thinking about it makes it worse in comparison to approaching the information.
Q: What if you don’t have 15 weeks to work with couples?
A: We have purposefully developed CBCT for PTSD to be a staged model. Therapists who may only have a short period to work with couples can choose to deliver one to three stages of the therapy, though the evidence base is for delivering all three stages of the therapy.
Q: Can you deliver the therapy to a couple if both partners have PTSD?
A: We have clinical experience in delivering the therapy to couples in which both partners have PTSD and at this point recommend delivering the first two stages of the therapy (sessions 1-7) as prescribed in the manual and increasing Stage 3 to include two sessions per topic area (starting at session 8). Two sessions per topic area in Stage 3 allows each partner who has PTSD to have a dedicated session where they really get to focus on their stuck points and then have a second dedicated session for the other partner. In other words, the same content is covered, but sessions are doubled in Stage 3 to ensure there is enough time for the therapist and each person to really work on stuck points in those areas.
Q: Would you include children or other family members in the therapy?
A: We are currently testing the therapy with other adult family and nonfamily members as dyads in the therapy (both romantic and nonromantic partners).
With regard to children, we have had some couples who have asked us to include their children in the therapy and we have done some psychoeducation sessions with school-aged children and up and have provided that psychoeducation in a developmentally appropriate way. Essentially, we have delivered some Session 1 information but have not included the children throughout the therapy.
In addition to the psychoeducation, a primary message for therapists to convey if they add children is that the parents’ problems are not the children’s fault. Further, the children have not caused their parents to have these issues, the children can’t solve these issues for the parents, the parents are working on it, and you are hopeful that things will get better for the family.
We have some preliminary evidence to suggest that even if you don’t include children in the conjoint therapy, there are improvements in overall functioning of the family and child outcomes.