The distress of post-traumatic stress disorder (PTSD) hurts not only the victims of trauma, but their loved ones as well, particularly their spouses or partners. Now a study suggests that a new type of couples therapy may help.
PTSD has been particularly devastating for veterans of the Afghan and Iraq wars — suicide, which is commonly linked with the disorder, is now killing more U.S. soldiers than combat itself. But even for those who don’t take their own lives, the combination of PTSD and traumatic brain injury (TBI), caused by repeated concussions during battle — both signature wounds of today’s wars — is profoundly disabling, as columnist Nick Kristof described in a harrowing article in the New York Times last Sunday. Because these brain wounds are not visible, unlike a lost limb, they often go unacknowledged by the sufferer, undiagnosed and untreated.
“[I]f you want to understand how America is failing its soldiers and veterans, honoring them with lip service and ceremonies but breaking faith with them on all that matters most,” Kristof wrote, you should consider the story of Maj. Ben Richards, a rising star in the U.S. Army, who was eventually diagnosed with both TBI and PTSD and nearly lost his marriage to his wife, Farrah:
A once boisterous dad who loved to roughhouse with his children — now there are four, ages 1 to 14 — Ben no longer seemed to know how to play with them. He often suffered incapacitating headaches, overwhelming fatigue and constant insomnia. Especially when dozing, he was on a hair trigger. If Farrah rose at night, she sometimes didn’t return to bed for fear that her husband might think she was an enemy and attack her. Instead, she’d spend the rest of the night on the couch.
For a woman who had been functioning as a single mom and was now eager to resume her former married life, all this was devastating. And it got worse. Farrah would tell her husband things, and then he would repeatedly forget — and reproach her for not telling him. He was distracted, withdrawn and unhelpful, and he repeatedly let her down.
“Our marriage was at real risk at this point,” Richards says. “We got to a point where we thought about separating.”
The hair-trigger nerves, irritability, inability to concentrate, insomnia and emotional withdrawal are all classic symptoms of PTSD, particularly when it is combined with brain injury. The Richards family is still struggling to get appropriate treatment.
Currently, counseling for PTSD focuses only on the individual with the disorder — and it does help. But while it improves patients’ psychological and social functioning, those improvements typically don’t occur in the context of their relationships with spouses or partners. What’s more, even when patients receive high-quality treatment for PTSD, research shows they are less likely to get better if their marital problems go unaddressed.
Although previous studies have suggested that couples counseling can help such patients improve both their PTSD symptoms and their relationship satisfaction, those studies have usually been small and lacking a control group. So, the new research, published in the Journal of the American Medical Association, sought to test the theory more rigorously. The trial involved 40 heterosexual and same-sex couples, half of whom were treated in an outpatient VA hospital clinic in Boston, and the other half who were treated at a university research center in Toronto, Canada.
The couples were randomly assigned either to receive a treatment called “cognitive behavioral conjoint therapy” or to put their names on a waiting list for treatment. The therapy itself began by teaching both members of the couple about the symptoms of PTSD, how the disorder affects their relationship and vice versa, and helping couples to feel safe talking about the disorder with each other. The first phase of treatment emphasized positive communication to break the cycle of negativity that often accompanies PTSD, which tends to lead both partners to become increasingly critical of each other. The authors noted that at the end of the first session, “the couple is instructed to catch each other doing nice things to promote positivity in their relationship and decrease selective attention to negativity.”
Over 15 sessions, the couples learned more about the impact of the particular trauma on their relationship and on the affected partner, including how PTSD can change the brain’s responses in ways that increase impulsivity, social withdrawal and aggression. The pairs were also instructed to try not to avoid circumstances — people, places, situations or feelings — that might trigger PTSD symptoms because that only reinforces the sufferer’s fear. Instead, they learned to push through the fear while making each other feel safe, such as by attending previously avoided social events together and learning that they can be pleasurable and fun, once their fear was overcome.
Compared with the couples who were waitlisted, the partner with PTSD in couples who underwent therapy showed a three times larger decrease in severity of PTSD symptoms. And the couples also reported four times more relationship satisfaction after therapy, compared with the control group. Indeed, after treatment, 81% of those in the treatment group no longer met the criteria for PTSD, compared with 63% of those on the waiting list. Three months later, the treatment group continued to do better than the controls.
The authors concluded that the treatment “produced improvements in clinician-rated PTSD symptoms…as well as patient-rated relationship satisfaction.” But because it’s still possible that the positive results were due simply to the fact that people in treatment got more therapeutic attention than those on the waiting list, couples therapy must be compared to another type of treatment to see exactly how effective it really is.
Still, the study’s findings fall in line with a wide range of research showing that social support from close relationships improves mental and physical health. They also suggest that a non-drug approach could improve PTSD, which is often difficult to treat.
“There is increasing recognition that intimate relationships play a potent role in recovery from PTSD,” the study authors write, and if their research is replicated, specialized couples therapy could be made available to veterans and others who struggle, along with their partners, with this often-invisible but devastating disorder.