Professional Psychology: Research and Practice
In the public domain
2005, Vol. 36, No. 6, 626 – 633
Key Elements in Couples Therapy With Veterans With Combat-Related
Posttraumatic Stress Disorder
Michelle D. Sherman, Dona K. Zanotti, and Dan E. Jones
Oklahoma City Veterans Affairs Medical Center
If a client dealing with combat-related posttraumatic stress disorder (PTSD) presents for psychotherapy,
should you consider including his or her partner in treatment? How could couples therapy be beneficial?
What framework do you have to conceptualize the relational issues and potential treatment? Although
clinicians have long been encouraged to include families in the treatment of combat-related PTSD, few
specific couple–family therapies exist, and outcome research is scarce. Because of the adverse effects of
PTSD on relationships, couples therapy can be a powerful adjunct treatment; however, few receive this
service. A new framework for conceptualizing couples therapy organizes treatment around the 3 PTSD
symptom clusters (reexperiencing, avoidance, and arousal). Relationship consequences of each symptom
cluster are summarized, followed by useful treatment interventions and a case study.
Keywords: posttraumatic stress disorder (PTSD), couples–family psychotherapy, trauma, veterans,
Soon many armed forces personnel will be returning from
tell us that families are dramatically affected and are instrumental
intense combat experiences in the Middle East, and they may face
in the veterans’ recovery. Unfortunately, clinicians have few re-
altered and challenging family situations upon their homecoming.
sources available for guidance in serving these families. Well-
In contrast to its state after previous wars, the field of psychology
designed couples therapy has the potential to help veterans cope
is now better prepared to treat individuals dealing with the after-
more effectively with trauma-related distress, to assist partners to
math of trauma, including posttraumatic stress disorder (PTSD).
understand and empathize with confusing behavior, and to
Clinicians are armed with numerous professional resources rang-
strengthen intimate relationships.
ing from empirical articles to detailed treatment guidelines to ideas
The inclusion of family members in the treatment of PTSD has
from professional conferences to masses of theoretical writings
been discussed in the clinical lore for years. For example, Figley
and books. However, what about the veterans’ families and their
(1988) has written extensively about PTSD and the family, includ-
potential role in treatment? Common sense and clinical intuition
ing a five-phase treatment approach that draws upon systems,
family stress, and family therapy theories. Other writers have
described the common symptoms and behavioral problems in
couples with PTSD and have suggested specific assessment strat-
MICHELLE D. SHERMAN received her PhD in clinical psychology from the
egies for these couples (e.g., Wilson & Kurtz, 1997). A few
University of Missouri—Columbia in 1997. She is employed by the
systemic family–marital therapies and psychoeducational marital
Oklahoma City Veterans Affairs Medical Center and affiliated with the
therapies (focusing on communication and problem-solving skills)
South Central Mental Illness Research, Education, and Clinical Center and
the University of Oklahoma Health Science Center’s Department of Psy-
have been developed as adjunctive treatments for PTSD; however,
chiatry and Behavioral Sciences. Areas of research interest include family
systemic examination of their efficacy is generally lacking (Riggs,
issues surrounding serious mental illness (especially posttraumatic stress
2000) and few families receive such services (Sherman et al.,
disorder [PTSD]) and couples–family psychotherapy.
DONA K. ZANOTTI received her PhD in counseling psychology from the
Given the large number of armed services members currently
University of North Dakota in 1998. She is employed by the Oklahoma
returning from Iraq and Afghanistan dealing with PTSD (Hoge et
City Veterans Affairs Medical Center and is affiliated with the University
al., 2004), attention to effective treatment modalities is critical.
of Oklahoma Health Science Center’s Department of Psychiatry and Be-
This article begins by outlining the rationale for including partners
havioral Sciences. Areas of research interest include PTSD and substance
in the treatment of combat-related PTSD, the potential benefits of
DAN E. JONES received his PhD in clinical psychology from Oklahoma
intervening at the couples level, and the small literature on empir-
State University in 1989. He is employed by the Oklahoma City Veterans
ical evaluations of dyadic treatments. A new framework is pre-
Affairs Medical Center and is affiliated with the University of Oklahoma
sented to guide clinicians in conceptualizing the effects of PTSD
Health Science Center’s Department of Psychiatry and Behavioral Sci-
on intimate relationships and on implementing effective couple
ences. Areas of research interest include anxiety disorders, especially
therapy interventions. Specific treatment recommendations are
provided for therapists, and a case study is described. (Because the
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Mich-
large majority of the research has been with male veterans, this
elle D. Sherman, Oklahoma City Veterans Affairs Medical Center, 921
article focuses on male veterans and female partners [typically
live-in significant others or wives]. Extrapolation of the research
KEY COUPLES THERAPY INTERVENTIONS FOR PTSD
findings to female veterans with PTSD will be important future
Rationale for Intervening at the Relational Level
Because of this complex interaction between veteran well-being
and broader family functioning, the inclusion of family members
Rationale for Including Family Members in Treatment
in treatment increases the likelihood of creating positive, enduring
change. Without helping the veteran address his individual trauma-
Research has clearly documented adverse effects of PTSD on
related issues and simultaneously altering the family’s expecta-
intimate relationships. Combat veterans experience a high rate of
tions of and ways of interacting with him, families will continue to
marital instability (Kessler, 2000), and veterans with PTSD and
engage in familiar, dysfunctional patterns. Treatment aimed at the
their spouses describe their marital problems in more severe terms
interpersonal context does the double duty of addressing the PTSD
than do veterans without PTSD (Riggs, Byrne, Weathers, & Litz,
symptoms within the context of strengthening the family’s cohe-
1998). Further, Vietnam veterans with PTSD are twice as likely as
siveness and supportiveness (Johnson, 2002) as well as dealing
those without PTSD to have been divorced and three times as
with family problems that arise as a result of PTSD.
likely to experience multiple divorces (Jordan et al., 1992). Fur-
The family experience of PTSD can become one-sided in that
ther, these relationship problems among veterans with PTSD ap-
the entire family unit can expend considerable energy helping the
pear to be chronic, as suggested by a recent study of World War II
veteran. Although this strategy may be functional at the time of
ex-POWs (Cook, Riggs, Thompson, Coyne, & Sheikh, 2004).
diagnosis and/or acute crisis, this approach reinforces the identi-
Ex-POWs with PTSD reported poorer relationship adjustment,
fied patient role of the veteran and ignores the partner’s needs.
poorer communication with partners, and more difficulties with
Couples therapy strives to move beyond this conceptualization and
intimacy than did ex-POWs without PTSD.
to balance the needs of both partners. Assisting both the veteran
Further, female partners of patients with PTSD are often un-
and partner to engage in perspective-taking behaviors helps them
happy with the relationship and quite distressed. Partners of vet-
to recognize and empathize with each other’s experience, thereby
erans with PTSD report lower overall satisfaction (Jordan et al.,
improving sensitivity to both parties’ needs and restoring a health-
1992), more caregiver burden, and poorer psychological adjust-
ier balance in the relationship.
ment (Calhoun, Beckham & Bosworth, 2002) than do partners of
Support for the efficacy of conjoint treatment in improving
veterans without PTSD. These family members also experience
marital adjustment and improving psychiatric functioning can be
high levels of caregiver burden (Beckham, Lytle, & Feldman,
found in research on depression (e.g., Beach, Fincham, & Katz,
1996). Recent research has also documented that these partners of
1996) and substance abuse (O’Farrell, Cutter, Choquette, Floyd, &
veterans with PTSD are highly distressed. For example, a recent
Bayog, 1992). Preliminary findings for PTSD also support the use
phone survey of 89 significant others of veterans with combat-
of relational therapy. For example, female sexual assault survivors
related PTSD (Manguno-Mire et al., 2004) found that the average
who were in relational therapy had greater reduction in symptoms
Global Severity Index of the Brief Symptom Inventory-18
of depression than did those in individual treatment (Bowling,
(Derogatis, 1993) exceeded the 90th percentile. Further, over three
2002); the groups experienced equal decreases in PTSD
quarters of partners in this study rate getting couples or family
therapy as very important in coping with the stress of PTSD in the
Further support for the importance of relational interventions
family (Sherman et al., 2005).
comes from the literature on supporting families of individuals
Intervening to help these partners manage their stress level and
with a serious mental illness such as schizophrenia. Caregivers
experience greater relationship satisfaction is important for the
who can cope effectively with the patient’s behavior report fewer
partner, the intimate relationship, and the veteran. Two lines of
psychosomatic symptoms and a lower level of burnout (Cuijpers &
research highlight this fact. First, increased stress in the family
Stam, 2000). An impressive literature on schizophrenia demon-
(especially tension and hostility) can trigger the veteran’s PTSD
strates the efficacy of family psychoeducation to significantly
symptoms. High levels of expressed emotion in the family have
reduce the risk of relapse, enhance social and family functioning,
been shown to impede improvement in patients with PTSD
and result in financial savings (Falloon, Roncone, Held, Cover-
(Solomon, Mikulincer, Fried & Wosner, 1987; Tarrier, Sommer-
dale, & Laidlaw, 2002). This mode of family intervention has been
field, & Pilgrim, 1999). Second, family members who are hurt by
applied to a variety of other mental illnesses, including bipolar
the veteran’s behavior are often reticent to provide support. This
disorder, major depression, and substance abuse (Sherman, 2003).
loss of social support is critical, as intimate relationships are a
primary source of support for most people (Beach, Martin, Blum,
& Roman, 1993). Further, high levels of social support have been
associated with decreased intensity of PTSD symptoms at 2 and 3
David Riggs (2000) delineated two major types of family inter-
years postcombat. Longitudinally, increased social withdrawal has
ventions for PTSD, including using partners as a source of social
been associated with increased PTSD intensity, and increased
support for the survivor in his or her recovery process and ad-
social contact was associated with decreased severity of symptoms
dressing systemic disruption in the relationship caused by expo-
(Solomon, Mikulincer, & Avitzuer, 1988). In addition to with-
sure to trauma (e.g., learning about effects of trauma, communi-
drawing support, some partners become critical and hurtful; the
cation skills, problem-solving skills). Riggs (2000) noted that these
survivors’ interactions with unsupportive partners are associated
strategies are not mutually exclusive.
with worsened mental health outcomes for the survivors (Byrne &
The only randomized clinical trial applying an empirically based
Riggs, 2002). This stressful family environment can then adversely
family intervention (behavioral family therapy) to PTSD did not
affect PTSD treatment (Tarrier et al., 1999).
result in any further reduction in symptomatology beyond that
SHERMAN, ZANOTTI, AND JONES
gained by previous exposure therapy. Furthermore, the study had
Partners may also adopt this disability-based view of the veterans,
a high dropout rate, both to enter and complete the family treat-
which can result in tolerating and excusing unwanted behavior
ment component of the trial (Glynn et al., 1999). The authors
because the veterans have PTSD. This conceptualization often
attributed this problem to the nature of the couples because their
deters couples from making positive relationship change. Couple
relationships were “obviously fragile” and because “the foundation
therapists face the challenge of respecting the couples’ anxieties
for making assumptions of cooperation, commitment and positive
and difficulties associated with his traumatic experience and of
feelings on the relative’s part was tenuous at best. Many of the
simultaneously inviting both the veteran and partner into greater
female partners were clearly angry and burdened and had limited
accountability for their behavior and the possibility of a paradigm
psychological resources available to support the veterans” (Glynn
shift. Couples can move beyond the conceptualization of the
et al., 1999, p. 249). Although this investigation had a small
“PTSD partner” being married to the “PTSD veteran” to a new
sample, it raised the possibility that couples in which one member
paradigm in which the woman sees herself as married to a man
has PTSD have specific, unique needs that were not addressed in
who has some challenges related to wartime experiences. The
the behavioral family therapy. Perhaps the partners were so angry
challenges he brings to the relationship are not qualitatively dif-
and overwhelmed that they were unable to learn, apply, and benefit
ferent from specific challenges she may bring that are associated
from the behavioral skills.
with other chronic conditions such as diabetes, heart disease, or
Another relational PTSD intervention studied Israeli couples in
which the veteran had PTSD because of experiences in the Leba-
Further, because of the dramatic nature of some of the veteran’s
non War. As part of a day treatment program (“Ko’ach”) for the
PTSD difficulties (especially the reexperiencing symptoms), ther-
veterans, several programs were provided for wives and couples,
apists’ immediate attention is often focused on symptom manage-
including education regarding symptoms, problem solving, com-
ment. As outlined below, early stages of therapy can involve
munication, and coping skills. Data collected 9 months posttreat-
helping couples communicate their wishes for how to cope during
ment revealed that 68% of the veterans felt their marital relation-
specific phenomena (e.g., nightmares or flashbacks). However,
ship had improved and 40% felt their PTSD symptoms were
solely focusing on managing the veteran’s symptoms is superficial,
reduced (Rabin, 1995; Rabin & Nardi, 1991).
reinforces a pathology perspective, and fails to address the deeper
dyadic dynamics. As documented above, partners are typically
distressed as well, but their symptoms are less conspicuous than
are those of the veteran; a sole focus on partners’ struggles would
In sum, PTSD couples experience significant discord, and the
also be one-sided. In-depth couples therapy takes into account both
partners are distressed and dissatisfied. Social support from the
parties’ experiences and needs and challenges couples to make
intimate partner is key to the veteran’s recovery, and literature
positive, sustainable changes in relational patterns to create more
from other diagnoses has demonstrated positive outcomes for
balanced, interdependent relationships.
family-based interventions. The only relational intervention for
As with most couples therapies, intervening with these couples
PTSD that has received rigorous empirical study yielded negative
requires that neither member is abusing substances and that the
findings, raising the question as to the need for specialized treat-
relationship is marked by physical safety (the issue of violence is
ment for these couples.
addressed below). Although abusing substances to distance from
The relationship problems couples dealing with PTSD encoun-
overwhelming emotions is common among veterans with PTSD
ter can be linked to the three clusters of PTSD symptoms (reex-
(Centers for Disease Control, 1988), the efficacy of couples ther-
periencing, avoidance, and increased arousal). Previous research
apy (in isolation) is compromised when this comorbid problem is
has documented many kinds of relationship difficulties among
not specifically addressed. In addition to addressing the couple’s
these dyads, but the current conceptualization provides a frame-
challenges described below, therapists should draw upon each
work for organizing assessment and treatment. In contrast to
couple’s unique strengths. Further, therapists can emphasize the
previous treatments that have failed to address all of these areas,
couple’s ability to grow closer and strengthen their relationship
effective comprehensive treatment of these couples will require
through sharing this experience.
assessment and intervention for all three domains. The proposed
Finally, therapists would be well served by drawing upon the
couple therapy interventions would be useful adjuncts to the vet-
marital therapy concept of acceptance (Jacobson & Christensen,
eran’s individual treatment. Couples counseling could precede
1996) in working with these couples. Promoting acceptance in
individual therapy, wherein the strength found in the relationship
dyads involves helping partners to tolerate and respect relational
could sustain the veteran through intensive treatment. On the other
differences rather than attempting to eliminate seemingly unsolv-
hand, couples therapy could follow individual treatment, thereby
able problems. Although the general focus of this article is striving
assisting in consolidating newly acquired skills and extending
for behavioral change, enhancing partner acceptance is powerful
them to the specific dynamics for that couple.
and often results in behavioral change.
The guiding principles that follow also challenge therapists to
help couples move beyond a focus on the veteran’s diagnosis as an
explanation and/or rationalization for behavior. Because of veter-
ans’ fear of losing the financial compensation associated with the
Consequences for the Relationship
disability, they sometimes expend considerable effort to maintain
their chart diagnosis of PTSD. Unfortunately, this scenario perpet-
These reexperiencing symptoms are often quite distressing for
uates the veteran’s need to exhibit dysfunctional behaviors and can
both the veteran and partner. Upon waking from a nightmare or
lead veterans to identify themselves according to their diagnosis.
recovering from a flashback, veterans frequently feel ashamed,
KEY COUPLES THERAPY INTERVENTIONS FOR PTSD
embarrassed, and anxious. Partners who witness these unpredict-
his or her observations and roles in the incident as well as their
able, uncontrollable acts often feel confused, afraid, and helpless.
reactions and possible learning from the experience. Helping the
Oftentimes the veteran does not want to discuss the details of the
couple to master a structured dialogue process can facilitate these
trauma and/or reexperiencing phenomena, so the partner feels left
oftentimes awkward discussions and can promote interpersonal
out and afraid. Because of bad dreams, couples may sleep in
learning and closeness; this process can then be used with non-
separate beds or rooms, which can interfere with physical and
PTSD-related relationship issues as well.
Help the couple in coping with upsetting reminders of the
For some veterans, the intrusiveness and unpredictability of
trauma that may trigger reexperiencing symptoms.
these symptoms render them unable to maintain steady employ-
efit from taking a team approach to coping with reminders. For
ment. Consequently, partners assume more occupational, financial,
example, they can anticipate the predictable difficult times (e.g.,
and household responsibilities, which can result in feeling over-
anniversaries of traumatic events) and plan in advance how to cope
whelmed (Matsakis, 1989; Verbosky & Ryan, 1988) and experi-
with the triggers. When partners are aware of potential challenges
encing high levels of caregiver burden (Beckham et al., 1996).
for the veteran, they can anticipate his increased anxiety and
Role ambiguity can arise with respect to delegation of household
provide extra understanding and support.
tasks, as veterans assume the identified patient role and other
family members take on greater responsibility.
Implications for Treatment
Consequences for the Relationship
Several important elements of effective dyadic PTSD treatment
Because of the avoidance symptoms (e.g., efforts to avoid
follow from these reexperiencing symptoms. Mental health pro-
reminders of the trauma, anhedonia, emotional detachment, re-
fessionals may choose to do any of the following:
stricted range of affect), veterans often become quite socially
Assist the veteran in educating his partner about reexperiencing
isolated. Because the partner often feels guilty leaving the veteran
Framing the veteran as the expert in his experience of
home alone, her enjoyment of socializing may be diminished.
PTSD is useful in helping the partner understand his situation.
When the partner does socialize independently, she often faces
Supporting the veteran in sharing his symptoms is preferable to a
questions as to the veteran’s whereabouts, which can be awkward.
didactic presentation from the therapist because his confiding in
The partner may feel embarrassed by the veteran’s absence or his
his partner promotes intimacy and sheds light on his unique
desire for early or rapid departure from events. Oftentimes, a
experience. When partners better understand the root of the reex-
partner will tire of solitary socializing so she becomes reclusive as
periencing symptoms, they can avoid personalizing the confusing
well, having few friends and social contacts. The partner may
behavior. Therapists may supplement the veteran’s sharing by
become resentful of the veteran for this isolated existence.
recommending bibliotherapy (e.g., Matsakis’s Vietnam Wives,
Not only do these couples become isolated from their extrafa-
1998b, or Trust After Trauma, 1998a).
milial contacts but the relationships are often marked by consid-
Assist the veteran in teaching his partner how to support him
erable emotional distance. Emotional intimacy, a prime predictor
Therapists can encourage the veteran to share
of marital satisfaction and stability (Gottman & Levenson, 1986),
with his partner how to assist him while he is reexperiencing the
is often impaired in veterans with PTSD (Roberts et al., 1982;
trauma. Helping the veteran to articulate his desires and then tell
Rosenheck & Thomson, 1986), likely due in part to emotional
them to the partner providing support is a powerful couples ther-
numbing (Cook et al., 2004). Veterans with PTSD often have
problems expressing caring (Egendorf, Kaduschin, Laufer, Roth-
1. If the veteran is unsure how the partner could be of help, the
bart, & Sloan, 1981), have low levels of self-disclosure and emo-
therapist may educate the partner about grounding techniques to
tional expressiveness (Carroll, Rueger, Foy, & Donahoe, 1985),
orient the veteran to the present situation.
have problems with sexual disinterest (Litz, Keane, Fisher, Marx,
2. Therapists can also use this situation as an opportunity to
& Monaco, 1992), and have ineffective interpersonal problem-
educate the couple about problem-solving skills. Through joint
solving skills (Nezu & Carnevale, 1987). Because of these factors,
ownership of the problem and brainstorming of potential solutions,
the intimate relationship may become emotionally dead or numb.
couples can develop effective strategies. Couples can also use the
Couples often describe themselves as cohabiting, living as room-
problem-solving skills in other situations.
mates, or living as brother and sister. Clinically it has been ob-
3. If safety is not addressed by the couple, therapists need to
served that individuals in these emotionally distant relationships
address the primary importance of safety for both people during
quite commonly engage in infidelity as a means of seeking
reexperiencing episodes. If the veteran becomes violent, the part-
ner needs an escape plan and/or a means of securing assistance. If
Further, because of the loss of friends in wartime, veterans may
the veteran is acting bizarrely but not harming anyone, partners
experience survivor guilt and associate emotional connection with
may benefit from engaging in self-care activities and obtaining
loss. During wartime, some veterans protect themselves by adher-
ing to the motto of “it don’t mean nothing.” Although this men-
Teach the couple a debriefing process to help deescalate the
tality can be functional in a combat situation, it results in veterans
situation and to promote learning from the episode.
avoiding and/or fearing intimacy. These difficulties with emotional
frequently struggle to find a productive, safe means of discussing
closeness manifest themselves in distant relationships marked by
these upsetting incidents, so therapy can involve educating dyads
low levels of trust. Research on partners of veterans with PTSD
about a debriefing process. Each member of the couple can share
has supported this phenomenon. A study of counselors from 100
SHERMAN, ZANOTTI, AND JONES
veterans centers (Matsakis, 1989) revealed that over 90% of part-
traumatic experiences often involve great powerlessness, it is
ners of combat veterans perceived reluctance on the part of their
critical that survivors have control over if, how much, when, and
partner to share emotionally, resulting in the partners feeling
how to share their experiences with their partners. The veteran can
lonely and isolated. Other research of interest has found that
be coached to let his partner know how to support him during and
partners of veterans with PTSD report greater fears of intimacy
after the sharing of his story. Systemic issues often arise surround-
(Riggs et al., 1998) than do partners of veterans without PTSD.
ing trauma stories, and a therapist can help the partner respect the
Finally, because of their decreased interest in previously en-
veteran’s choices surrounding disclosure. The partner may need
joyed activities, veterans with PTSD often spend a great deal of
assistance in coping with the veteran’s decision to perhaps share
time in solitary, unfulfilling activities (e.g., watching TV, sleep-
more about his trauma with fellow veterans than with her. Regard-
ing). Veterans who gained a strong sense of identity as a soldier
less of the veteran’s decision regarding disclosure, therapists may
protecting his country may be overcome with depression because
help the veteran explain to his partner what meaning the trauma
of the seemingly meaningless existence. Given the veteran’s de-
holds for him; the couple can then process the trauma’s meaning
pression and emotional withdrawal, the couple rarely engages in
for them as a couple.
joint enjoyable activities, which deepens the chasm in the already
Encouraging the pursuit of enjoyable activities (both individu-
ally and as a couple) because of the social isolation that commonly
results from the avoidance.
Therapists may choose to do any of
Implications for Treatment
1. Behavioral activation strategies are useful for veterans who
Because of these avoidance symptoms, therapists may intervene
demonstrate low interest in activities. As has been effective with
with couples by doing one of the following:
individuals with depressive disorders, this intervention can in-
Engaging the couple in assessing their readiness and commit-
crease the person’s involvement with pleasurable activities and
ment to the difficult work involved in strengthening their emotional
create opportunities for social connection. Therapy may involve
Sometimes both individuals cease efforts to create connec-
brainstorming activities that have a high chance of success (e.g.,
tion and increase the intimacy in the dyad, resulting in estranged
participation in veterans groups) and help the veteran cope with
relationships. In these situations, couples may be engaged in
social anxiety that may interfere with his participation.
reflection on the pros and cons of the current arrangement. They
2. To help partners cope with some of the solitude involved in
may have settled into an unhappy but familiar situation, believing
living with a veteran with PTSD, the therapist may encourage
that emotional reconnection is unattainable or perhaps even unde-
partners to create and use their own support networks and enjoy
sirable. Therapy can involve discussion of the potential benefits
hobbies. Systemic issues likely arise in these discussions, so ther-
and fears surrounding the risks of attempting intimacy with one
apists may ensure that the veteran supports the partner in pursuing
individual activities. Therapy may involve helping the veteran
Empowering the couple to risk trust and openness with each
attend to consequences of his isolative behaviors for his partner
other (if they commit to building intimacy in their relationship).
and their relationship. Further, the therapist may need to attend to
Cognitive interventions with the veteran may be useful in helping
the partner’s guilt for enjoying herself when the veteran chooses to
him to realize that his approach during wartime of keeping others
at bay is no longer necessary. A therapist may assist the partner in
3. Finally, therapy can involve encouraging couples to engage in
avoiding personalizing the veteran’s distancing behavior, therein
joint activities, which can serve the dual function of helping with
helping her to understand the veteran’s use of distancing as a
the veteran’s avoidance and strengthening the relationship. Ther-
coping strategy. The specific interventions that may be useful in
apy may also involve the use of behavioral interventions to in-
strengthening the emotional connection in the dyad may include
crease mutual expressions of care (e.g., caring behaviors, expres-
sions of appreciation).
1. Interventions based on Dr. John Gottman’s work of helping
Teaching interpersonal problem-solving skills.
couples respond to bids for emotional connection by turning to-
many veterans attempt to avoid facing relational problems directly,
ward each other rather than turning away or against (Gottman &
couples therapy can involve education, role plays, and rehearsal of
these fundamental skills. Problem-solving skills may also be useful
2. Interventions based on Dr. Susan Johnson’s emotionally
for helping couples negotiate many other relational issues such as
focused therapy (Johnson, 2002), which draws upon an
finances and the sharing of household responsibilities.
attachment-based paradigm of using your partner as a secure base
in navigating the challenges and traumas in life.
3. Basic communication skill training, which is especially im-
portant given the restricted range of emotions for veterans with
Consequences for the Relationship
PTSD. Therapists may assist both partners in the identification,
labeling, and expression of emotions, followed by coaching of the
Many symptoms in this cluster can have significant effects on
listener in responding in a supportive manner. Education about the
veterans’ relationships. For example, his sleep disturbance and
emotional numbing common to PTSD can also be useful.
consequent fatigue may exacerbate his social withdrawal, anhedo-
Empowering the couple to negotiate how much of the trauma is
nia, and irritability. The hypervigilance and startle response com-
shared in the relationship.
Although veterans sometimes avoid
monly associated with PTSD may exacerbate the veteran’s social
talking about the traumatic event, other times veterans choose to
withdrawal. Living in a chronic state of heightened arousal can
share some of their experiences with loved ones. Given that
also add tension and stress to the intimate relationship. Partners
KEY COUPLES THERAPY INTERVENTIONS FOR PTSD
may also “walk on eggshells” because of fear of upsetting the
means of conflict resolution (via nonviolence contracts or time-out
Chronic low-grade irritability can erode the positive feelings in
Assist the couple in coping effectively with irritability and/or
the relationship, resulting in partners becoming critical and/or
expressions of anger.
This multifaceted dynamic pertains only to
emotionally disengaged from the relationship. Research has doc-
nonabusive irritability. Therapy can involve exploration of one’s
umented that displays of anger are linked to decreased motivation
triggers for anger and education about ways of coping with frus-
in others to offer support (Lane & Hobfoll, 1992).
tration. Basic education about the experience of the emotion of
As exemplified in the criterion of angry outbursts, the risk for
anger and the choices one has in coping with it may be useful.
perpetrating domestic violence is also elevated among veterans
Helping the veteran to identify times when he may displace his
with PTSD (Jordan et al., 1992). For example, one study of
trauma-related anger onto his partner can be productive. Further,
Vietnam combat veterans and their partners (Byrne & Riggs, 1996)
assisting the partner in respectfully providing feedback about his
revealed that 42% of the men had engaged in physical aggression
behavior can assist him in changing his hurtful acts and can
against their partners in the previous year, 92% had been verbally
aggressive, and 100% had used psychological aggression. Among
Teach conflict disengagement strategies.
A time-out process
couples dealing with PTSD seeking marital therapy, the rates of
can be very useful in preventing escalation of conflicts and creat-
veteran to partner physical violence are even higher (Sherman,
ing emotional safety in the relationship. Therapists may teach the
Sautter, Jackson, Lyons, & Han, 2004). This increased risk of
couple this strategy, do role plays in session, and encourage
perpetrating intimate partner violence is logical given the high
rehearsal during the week as homework.
comorbidities between PTSD and several other variables (e.g.,
Educate the couple about anxiety management strategies and
depression, substance abuse, relationship distress, impaired
sleep hygiene tips.
Given the ripple effects of the veteran’s
problem-solving skills) known to be related to heightened risk for
anxiety to the broader relationship, both members of the relation-
perpetrating violence (Riggs, 1997).
ship can benefit from learning coping strategies for anxiety and
insomnia. The veteran may help the partner to understand his fears
Implications for Treatment
about being startled and his worries about letting down his guard;
he may also solicit her support during times of high anxiety.
Given this increased arousal, couples therapy can address sev-
eral important relational dynamics. Therapists may choose to do
any of the following:
Assist the couple in giving feedback about their needs and
setting limits on emotional involvement.
On the basis of exten-
To illuminate the usefulness of these interventions, we describe
sive research with well-adjusted couples, Dr. John Gottman de-
a case study that demonstrates positive therapeutic gains for a
fined the phenomenon of flooding as an experience wherein the
couple; several elements of this conceptual framework were in-
individual is emotionally overwhelmed and physiologically
corporated in their treatment.
aroused, rendering him or her much less effective in communicat-
John, a 55-year-old African American man, has been married to
ing with a significant other (Gottman & Silver, 1999). Combat
a 46-year-old African American woman, Mary, for 8 years; this is
veterans frequently refer to the experience of being emotionally
John’s third marriage and Mary’s second marriage. John retired
flooded and unable to remain emotionally present; veterans admit
from long-haul truck driving 3 years ago and receives disability
to disappearing or mentally “tuning out” when unable to tolerate
from the U.S. Department of Veterans Affairs for combat-related
emotionally stressful situations. Similarly, partners can feel quite
PTSD. Mary works full time and has adult children from her
overwhelmed and distressed by emotionally stressful situations,
previous marriage. John recently completed an intensive PTSD
including the veterans’ reexperiencing behaviors and the trauma
program and feels proud of his progress; his case manager recom-
stories. It is important that couples develop and implement a
mended couples therapy as part of his aftercare plan.
nonjudgmental means of setting limits on emotional discussions.
John and Mary present to couples therapy with four major
Therapists can help the couple to let each other know when
needing time or space. This boundary-setting process is important
1. The couple feels like roommates and has minimal emotional
in all couples but may be especially relevant for dyads in which
connection; they discuss only superficial topics for fear of ap-
both have experienced traumatic events (Balcom, 1996).
proaching potentially volatile issues (avoidance of intimacy).
Assess for domestic violence in every couple.
Given the ele-
2. John’s anxiety deters him from socializing; because of Mary’s
vated rates of domestic violence in this population, a thorough,
discomfort with going out alone, she has discontinued many ac-
specific, multimodal assessment of violence with every couple is
tivities as well. Hence, John spends most of his time at home alone
essential (O’Leary, Vivian, & Malone, 1992). If violence is de-
(social avoidance), and Mary occupies herself with her children’s
tected, each individual should be referred to separate, specialized
domestic violence services (e.g., hotlines, shelters, counseling;
3. John has a bad temper and feels guilty for his past verbal and
legal aid for the partner; batterers treatment programs for the
physical aggression toward Mary; she feels like she’s always
veteran). Couples therapy is contraindicated in the presence of
“walking on eggshells” around him. She wants to trust that he’s
severe physical abuse, as it can place the victim at greater risk
made progress in treatment but harbors painful memories of his
for additional injury (Gauthier & Levendosky, 1996). However,
past outbursts (increased arousal).
therapists specially trained in treating family violence may as-
4. Because of John’s frequent distressing nightmares, the couple
sist couples with lower levels of aggression to use nonviolent
has slept in separate beds for most of their married life; they seek
SHERMAN, ZANOTTI, AND JONES
information on how to cope with his nightmares and intrusive
family life cycle, whether the trauma preceded or followed the
thoughts (reexperiencing symptoms).
initiation of the relationship, and relationship length. The extent to
Given the history of violence, treatment began with a thorough
which this proposed conceptual framework applies to noncombat
assessment of intimate partner violence and efforts to ensure the
trauma is uncertain; future literature will need to address whether
safety of both parties. Assessment data (self-report data collected
certain kinds of interventions are also needed for specific traumas
before the intake appointment and clinical assessment in the first
(e.g., addressing sexual issues after sexual trauma).
interview) revealed that there had been no physical violence in
Given the growing understanding of PTSD and its impact on the
over 5 years. To prevent future violence and to help cope effec-
family, development of evidence-based intervention strategies is
tively with the friction that occurs in any relationship, the therapist
important. Program development should be grounded in empirical
taught a time-out process and engaged in problem solving with the
research findings and clinically driven guidelines such as those
couple regarding its use. Given the couple’s history of highly
offered herein. As assessment tools and treatment programs are
emotional conflict, the therapist normalized occasional regression
developed, a comprehensive program of research is needed to
to volatile arguments but provided a new framework for an argu-
evaluate their effectiveness.
ment’s aftermath. The couple learned a structured dialogue to
In sum, in light of the many families dealing with the aftermath
guide them in debriefing from the incident. Through using this
of insidious traumatic events, adjunctive couples therapy can foster
specific format, John and Mary learned that they are more vulner-
interdependent, balanced intimate relationships and can be an
able to explosive interchanges when they are tired or physically
important element in the comprehensive treatment of PTSD. As
sick and that their communication is much more effective after
seen in the case of John and Mary, couples therapy has the
having taken a time-out to calm down.
potential to help both members of the couple function more effec-
As the couple implemented these skills, their sense of interper-
tively, to promote intimacy in the relationship, and to assist in
sonal safety and trust increased. John and Mary wanted to learn
reducing the intensity of the veteran’s symptoms of PTSD.
how to talk about difficult matters more easily, so therapy next
involved teaching communication skills to facilitate honest, re-
spectful dialogue. As their communication became more open and
comfortable, John expressed guilt for how his PTSD symptoms
Balcom, D. (1996). The interpersonal dynamics and treatment of dual
contribute to the couple’s social isolation. Therapy then involved
trauma couples. Journal of Marital and Family Therapy, 22, 431– 442.
exploring activities that were previously enjoyable for the couple
Beach, S. M., Martin, J. K., Blum, T. C., & Roman, P. M. (1993). Effects
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grew, ambivalence arose about risking greater emotional intimacy,
which was explored therapeutically by reviewing their hopes and
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