Perlick et al. Military Medical Research (2017) 4:21 DOI 10.1186/s40779-017-0130-9

REVIEW Open Access The incorporation of emotion-regulation skills into couple- and family-based treatments for post-traumatic stress disorder Deborah A. Perlick1,2*, Frederic J. Sautter3,4, Julia J. Becker-Cretu3,4, Danielle Schultz1,2, Savannah C. Grier1, Alexander V. Libin5,6, Manon Maitland Schladen5,6 and Shirley M. Glynn7,8

Abstract Post-traumatic stress disorder (PTSD) is a disabling, potentially chronic disorder that is characterized by re-experience and hyperarousal symptoms as well as the avoidance of trauma-related stimuli. The distress experienced by many veterans of the Vietnam War and their partners prompted a strong interest in developing conjoint interventions that could both alleviate the core symptoms of PTSD and strengthen family bonds. We review the evolution of and evidence base for conjoint PTSD treatments from the Vietnam era through the post-911 era. Our review is particularly focused on the use of treatment strategies that are designed to address the emotions that are generated by the core symptoms of the disorder to reduce their adverse impact on veterans, their partners and the relationship. We present a rationale and evidence to support the direct incorporation of emotion-regulation skills training into conjoint interventions for PTSD. We begin by reviewing emerging evidence suggesting that high levels of emotion dysregulation are characteristic of and predict the severity of both PTSD symptoms and the level of interpersonal/marital difficulties reported by veterans with PTSD and their family members. In doing so, we present a compelling rationale for the inclusion of formal skills training in emotional regulation in couple−/family-based PTSD treatments. We further argue that increased exposure to trauma-related memories and emotions in treatments based on learning theory requires veterans and their partners to learn to manage the uncomfortable emotions that they previously avoided. Conjoint treatments that were developed in the last 30 years all acknowledge the importance of emotions in PTSD but vary widely in their relative emphasis on helping participants to acquire strategies to modulate them compared to other therapeutic tasks such as learning about the disorder or disclosing the trauma to a loved one. We conclude our review by describing two recent innovative treatments for PTSD that incorporate a special emphasis on emotion-regulation skills training in the dyadic context: structured approach therapy (SAT) and multi-family group for military couples (MFG-MC). Although the incorporation of emotion-regulation skills into conjoint PTSD therapies appears promising, replication and comparison to cognitive-behavioral approaches is needed to refine our understanding of which symptoms and veterans might be more responsive to one approach versus others. Keywords: couples, family, post-traumatic stress disorder, emotional regulation

* Correspondence: [email protected] 1JJPeters Department of Veterans Affairs Medical Center and VISN2 South Mental Illness Research, Education and Clinical Center, 130 West Kingsbridge Rd, Bronx, NY 10468, USA 2Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, USA Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Perlick et al. Military Medical Research (2017) 4:21 Page 2 of 10

Background the severity of PTSD symptom clusters. For example, Post-traumatic stress disorder (PTSD) is a potentially Monson et al. [14] found that difficulty associated with chronic, impairing disorder that is characterized by re- describing feelings was a significant predictor of the level of experience and hyperarousal symptoms as well as negative re-experience symptoms only, whereas negative affect was cognitions and avoidance of trauma-related stimuli [1]. In associated with the severity of avoidance/numbing, hyper- returning veterans, PTSD frequently presents with co-oc- arousal and re-experience symptoms among veterans who curring depression, substance abuse and traumatic brain were enrolled in an intensive PTSD treatment program. injury [2]. Although PTSD is an individually diagnosed Anger is also predictive of PTSD severity, particularly hy- disorder, many of its core symptoms can lead to disrup- perarousal symptoms [17]. Nevertheless, a survey of 676 tions in close relationship such as detachment or estrange- veterans [18] found that self-reported aggressive urges were ment or have the potential to create interpersonal conflict associated with the severity of re-experience symptoms, due to irritability, anger, severe agitation [3] or reckless be- whereas difficulty managing anger was associated with the havior [4–7]. In this paper, we discuss the important role severity of avoidance symptoms. Studies of combat veterans that emotion regulation, defined as the ability to change have consistently found significant associations between the thefrequency,intensity,and/ordurationofemotion[8], PTSD symptom level and anger, even after accounting for plays in the process of veterans’ learning to join with their demographic and exposure variables [19]. partner or family member to reduce veterans’ PTSD and Not surprisingly, high levels of PTSD have frequently its negative impact on the veterans’ intimate relationships. been associated with relationship distress (e.g., [20–22]), We begin by reviewing emerging evidence that: 1) high poor family functioning in veterans [2, 23] and intimate levels of emotion dysregulation are characteristic of and partner violence in veterans [24]. Taft and colleagues predict PTSD severity and 2) high levels of emotion dys- [24] found medium-sized associations in a meta-analytic regulation are associated with the severity of interpersonal investigation of 31 studies on the association between and/or marital difficulties among veterans with PTSD and PTSD severity and interpersonal psychological and phys- their partners or family members. Second, we discuss both ical aggression, with the largest effects observed in mili- the rationale and the therapeutic strategies for incorporat- tary samples. Evans et al. [2] evaluated the impact of ing emotion-regulation skills training into couple- and PTSD symptom clusters on family functioning via path family-based interventions for PTSD. Third, we review the analysis, finding both a significant direct effect of avoid- evolution of couple therapy for veterans with PTSD, par- ance symptoms on overall family functioning and an in- ticularly focusing on randomized clinical trials that were direct path via the effects of avoidance symptoms on conducted with veterans. In this context, we describe two depression. Hyperarousal symptoms had an indirect as- recent innovative couple-based treatments for PTSD that sociation with family functioning that was mediated by incorporate a special emphasis on emotion-regulation the association between arousal symptoms and anger, skills training in the dyadic context. Structured approach whereas re-experience symptoms did not impact family therapy (SAT) [9] seeks to improve couples’ ability to man- functioning in this study. age trauma-related emotions by providing skills training in awareness, labeling, and acceptance of emotions as well as Rationale and strategies for incorporating in distress tolerance. Multi-family group for military cou- emotion-regulation skills training into couple- ples (MFG-MC) [10, 11] teaches skills in mindfulness, dis- and family-based interventions for PTSD tress tolerance, and more advanced emotion-regulation The association between PTSD symptom severity and both strategies to add this important dimension to communica- emotion dysregulation and couple and family relationship tion skills training in subsequent sessions. Fourth and fi- distress makes a compelling case for incorporating nally, we discuss the limitations and challenges of the work emotion-regulation skills into family-based interventions to date and future directions for research in this area. for PTSD. Learning theories of PTSD predict that the increased exposure to trauma-related memories and PTSD symptoms, emotion dysregulation, and emotions will decrease the veterans’ PTSD. However, suc- family/marital difficulties cessful exposure requires the veterans and their partners to Many returning veterans with PTSD show emotion regula- develop the ability to manage the uncomfortable emotions tion problems [12–14], and difficulties in emotion regula- that they previously avoided. Studies have shown that tion have been linked to PTSD symptom severity [15, 16]. adapting to PTSD-related emotions requires veterans to Such difficulties include problems in the identification and develop the ability to increase their acceptance and aware- expression of emotion as well as in the ability to tolerate ness of aversive emotions while also accessing effective negative affect and traumatic event cues without feeling emotion-regulation strategies and minimizing impulsivity overwhelmed or losing control. Specific problems with and avoidance [25]. Learning and practicing emotion- emotion regulation have been differentially associated with regulation skills has the potential to be particularly Perlick et al. Military Medical Research (2017) 4:21 Page 3 of 10

powerful in the dyadic context for returning Operation and began to develop intervention models that were typic- Enduring Freedom/Operation Iraqi Freedom/Operation ally grounded in existing structural, strategic, narrative New Dawn (OEF/OIF/OND) veterans. The majority of and/or dynamic approaches to family therapy to facilitate OEF/OIF/OND couples is married/cohabiting and faces the recovery of the traumatized veteran and the develop- major challenges in association with reconnecting and re- ment of a new family equilibrium [28–34]. These authors negotiating roles post-deployment [26]. Couples’ interac- often illustrated their approaches with compelling clinical tions often elicit strong emotions, which can lead to vignettes but did not publish empirical data to support behaviors that create stress and can lead to relationship dis- their models. Consistent with the family therapy traditions solution if the partners’ emotion-regulation skills are poor. from which they evolved, these approaches were primarily One report found that 35% of veterans who were receiving experiential and included little formal skills training. Veterans Affairs (VA) care reported separation or divorce The late 1980s and early 1990s ushered in a new era in within 3 years of their homecoming [27]. Couples who couples interventions, with a greater emphasis on meth- learn to regulate emotions successfully through conjoint odological rigor and empirical testing of outcomes. work for PTSD might experience the simultaneous benefit Although these new conjoint interventions were first con- of enhancing the relationship while addressing the disorder. ceptualized as a way to address relationship distress, they have subsequently been applied to PTSD. Johnson et al.’s Evolution of couple- and family-based interventions [35] emotionally focused couple therapy (EFT) is for PTSD grounded in attachment theory and proposes that repair- Several papers on conjoint or family-based approaches ing attachment ruptures and restoring intimate connec- to the treatment of combat-related PTSD have been tions are the key therapeutic tasks in couple therapy. EFT published in the last 30 years. These interventions often consists of three stages: de-escalation of the couple’s not only incorporate components that have been found negative cycle (stage I), restructuring of problematic inter- to be effective in individual treatments (e.g., cognitive actions (stage II), and consolidation/integration (stage III). restructuring) but also include interventions that involve In successive steps in stage II, individuals are assisted in dyadic work such as communication skills training. voicing both their attachment needs and their deep Although the developers of these interventions all ac- emotions and then prompted to express acceptance and knowledge the importance of emotions in PTSD, the compassion for their partner’s attachment needs and treatments vary widely in their relative emphasis on emotions. Over time, as trust develops between the part- helping participants to acquire strategies to modulate ners, increasingly more conflictual topics are addressed. them compared to other therapeutic tasks such as learn- Interactions are guided by the therapist, who has an ing about the disorder or disclosing the trauma to a overarching goal of supporting the (re)attachment of the loved one. None of the interventions is defined as pri- partners. However, the attention paid here to understand- marily involving emotion regulation, although teaching ing and modulating emotions in the service of securing skills such as active listening and taking a time-out this connection could also be understood in the rubric of clearly promotes more control over affect. In this emotion regulation. section, a brief overview of couples work with PTSD is EFT has been evaluated in distressed couples in the presented, with an emphasis on veteran samples. We community in open as well as randomized controlled begin with preliminary papers, which often provided trials (RCTs), with relatively consistent findings of im- theoretical applications and case descriptions of estab- provements in relationship satisfaction and/or empathy lished couples interventions to combat-related PTSD. resulting from engagement in therapy ([36–38]; see [39] We then move to presentations of more rigorously for a review). There have also been EFT investigations in controlled trials of conjoint interventions with veterans. couples facing the aftermath of trauma. Improvements in We conclude with more detailed descriptions of SAT both the relationship and trauma symptoms were ob- and MFG-MC [9–11], two newer veteran couples inter- served in 10 couples who were participating in EFT in ventions for PTSD that have an explicit focus on emo- which one member had a history of childhood sexual tion regulation. abuse and a diagnosis of PTSD [40]. Dalton et al. [41] con- ducted a randomized controlled trial to examine the effi- Preliminary work: uncontrolled trials and case studies cacy of EFT in 32 couples in which the female partner had The distress that is experienced by many veterans of the experienced past childhood abuse. A diagnosis of PTSD Vietnam War and their partners prompted a strong was not an inclusion requirement. The couples were ran- interest in developing conjoint interventions that could domly assigned to 24 sessions of EFT or a waitlist control both alleviate symptoms of PTSD and strengthen family group. Compared to the waitlist condition, participation bonds. Many clinicians wrote thoughtfully about the diffi- in EFT was associated with significantly greater relation- culties associated with family reintegration after combat ship satisfaction scores posttreatment, although there was Perlick et al. Military Medical Research (2017) 4:21 Page 4 of 10

no impact of EFT on trauma symptoms. As cited in Larger randomized clinical trials of couple/family work Wiebe and Johnson [39], Weissman et al. conducted an relating to PTSD open EFT trial with 7 veterans who were diagnosed with Researches in mental health in the late 1980s and 1990s PTSD and found reductions in PTSD symptoms as well as were influenced by growing specification regarding the im- increases in mood and relationship satisfaction. Greenman pact of environmental stressors, including family tension and Johnson [42] also applied the EFT model to PTSD and conflict, on outcomes relating to psychiatric disorders. treatment in veterans using a case example. Outcome data The diathesis-stress model [48] proposes that the extent of were not available, as the couple was still in treatment the expression of a biological vulnerability to a disorder when the article was written. Unfortunately, more (i.e., the diathesis) is influenced by the degree of exposure rigorous research of EFT with combat veterans is lacking to stress. As applied to PTSD, the theory proposes that to date. once the disorder develops (as a result of exposure to ex- Erbes, Polusny, MacDermid, and Compton [43] applied treme environmental stress), the survivor is extremely sen- integrative behavioral couple therapy (IBCT; [44]) to treat sitive to subsequent ambient stress, including negative combat-related PTSD. The goal of IBCT is to reduce appraisals by relatives. This theoretical framework implies marital distress by enhancing partners’ acceptance of each that potentially effective interventions might focus on the other. The intervention entails providing initial tailored reduction of ambient stress by teaching the trauma survivor feedback to the couple based on a thorough assessment, andhis/herlovedonesspecificskillstopromoteeffective promoting partners’ empathy towards each other and communication and problem solving to minimize conflict supporting the couples’ adoption of a unified approach to in the home environment and cope with life’s challenges the problems that they face, rather than blaming each successfully. other. Some couples are provided with advanced work re- Behavioral family therapy (BFT) is grounded in the lating to distress tolerance in which they are guided to diathesis-stress model of psychiatric illness and includes ill- interact in the session around a previously emotionally ness education, communication skills training, and loaded issue using their new empathy and unified ap- problem-solving instruction. Glynn et al. [49] conducted a proach to the problem. Erbes et al. [43] posited that IBCT randomized trial comparing the additive benefits of BFT to might be particularly effective for PTSD survivors because prolonged exposure in a trial of Vietnam veterans diag- it reduces couple conflict and increases intimacy through nosed with combat-related PTSD. Vietnam veterans and a fostering acceptance, tolerance, and the expression of pri- family member (90% of whom were conjugal partners) were mary emotions such as fear or sadness that often underlie randomized to a) wait list, (b) 18 sessions of twice-weekly the chronic anger that is associated with PTSD. However, exposure therapy (ET), or (c) 18 sessions of twice-weekly aside from the limited work on distress tolerance exposure therapy followed by 16 sessions of behavioral highlighted above, the approach does not involve any family therapy (ET + BFT). Although the study findings did formal emotion-regulation skills training. Although there not support the hypothesis that adding BFT to ET would is a considerable evidence base for IBCT in community improve treatment outcomes, they did indicate that both samples [45], it has not been evaluated in controlled the ET and the ET + BFT conditions improved re-experi- research for the treatment of PTSD. The application of ence and hyperarousal symptoms compared to the wait list IBCT to PTSD in Erbes et al. [43] has been illustrated control group. Although they were not statistically signifi- with only a case example to date. cant, the ET + BFT group was associated with reductions Sherman and colleagues developed a conjoint educa- in re-experience and hyperarousal symptoms that were ap- tion and support program Reaching Out To Educate and proximately twice the magnitude of those obtained in the Assist Caring, Healthy (REACH) Families [46] tailored ET group. Additionally, there was an overall effect size ad- to the unique needs of families of returning OEF/OIF/ vantage (d =0.46)forET+BFTcomparedtoETalone. OND veterans that incorporated aspects of the multiple- There was no effect on numbing or avoidance symptoms. family group therapy format for serious mental illness This pattern of results suggested that family interventions (SMI) proposed by McFarlane et al. [47]. REACH is might have some value in treating PTSD. However, more primarily educational but includes some discussion of interventions need to be developed. managing negative affect as well as formal skills training Monson et al. [50] developed a manualized conjoint, and out-of-session practice. Sherman and colleagues skills-focused treatment for PTSD called cognitive- have not tested the benefits of REACH in randomized behavioral conjoint therapy (CBCT). CBCT for PTSD trials but have presented data on knowledge gains consists of 15 75-min sessions and incorporates many accrued in the groups and participant satisfaction [46] aspects of cognitive processing therapy [51, 52] that suggest that participants learn about PTSD and conducted in a conjoint frame. As such, the primary other mental health issues and find the intervention to therapeutic goal is to harness social support to modify be accessible and helpful. dysfunctional trauma-related cognitions to reduce PTSD Perlick et al. Military Medical Research (2017) 4:21 Page 5 of 10

and support successful reintegration. CBCT has three complex emotional states that develop in people who must phases: (1) education about PTSD and its effect on adapt to trauma and adversity over more extended periods relationships and safety building, (2) communication of time [61]. skills training and couple-oriented in vivo exposure to The newer PTSD couple interventions that are pre- overcome behavioral and experiential avoidance, and (3) sented next are grounded in this conceptualization of cognitive interventions aimed at changing problematic emotion. They incorporate explicit strategies to increase trauma appraisals and beliefs that maintain PTSD and distress tolerance and emotion-regulation skills while relationship problems. A key therapeutic goal is to enhancing the couple’s awareness and understanding of support the dyadic frame. That is, the couple engages in affect. Complementary therapeutic goals include engen- the healing activities together and shares responsibility dering acceptance of emotions and the ability to regulate for recovery. There have been positive findings from behaviors in accordance with long-term relationship goals, small uncontrolled studies with combat veterans who even while experiencing strong negative emotions. This were diagnosed with PTSD [53, 54]. The RCT confirm- training in the acceptance and regulation of emotions ing the benefits of CBCT on PTSD symptoms (effect allows the veteran and his or her partner to use situation- size =1.13 on the Clinician-Administered PTSD Scale ally appropriate emotion-regulation strategies in a flexible [55]) and relationship functioning (effect size = 0.47 for manner to modulate emotional responses [62, 63]. We the survivor on the Dyadic Adjustment Scale [56]) was have developed treatment models for both individual conducted with a mixed community veteran sample with (SAT [9]) and couple group interventions (MFG-MC) [11] broad trauma exposure. There were 9 veteran partici- that incorporate emotion-regulation (ER) skills training as pants, 2 of whom had a combat-related PTSD diagnosis. a major therapeutic component to treat PTSD with com- bat veterans and have had some success. Newer couples treatments for PTSD with an emphasis on emotion-regulation skills training Structured therapy approach Although the interventions described above incorporate Data from Glynn et al.’s [49] study described above showing some features that are designed to address emotion dysreg- that BFT + ET reduced re-experience and hyperarousal ulation in association with PTSD and the negative impact symptoms but not symptoms of avoidance and emotional on couples, they have not systematically implemented numbing indicated the need to target the latter symptoms emotion-regulation skills training as explicit therapeutic more directly. Sautter and Glynn used these findings as the tasks. These studies do not provide guidelines for defining basis for a new couple-based PTSD treatment called which emotion-regulation skills should be included and structured approach therapy (SAT). Conducted by a single which symptoms or deficits are most likely to be addressed. therapist with a single couple, SAT is designed to help the Because emotion regulation might be crucial to achieving partners to decrease their avoidance of trauma-related favorable PTSD treatment outcomes [54], it is important to stimuli and to enhance their emotion regulation. base our interventions on theoretical models of emotions SAT is a phasic PTSD treatment that includes out-of- and emotional functioning that are consistent with our session practice. The first phase of SAT consists of conjoint understanding of PTSD [12, 53]. It has been hypothesized illness education that provides the couple with information thattheexperienceoftraumagenerates acute reactions of regarding trauma and describes how trauma impacts the fearandanxiety,followedbythedevelopmentofmore processing of emotions that are crucial for maintaining in- enduring emotions that require regulation across varied timate relationships. The second phase of SAT consists of a environmental and social contexts [8, 57]. The processing skills-training component in which the partners are taught and regulation of emotions have been described as a set of to identify, label and communicate about their avoidance of experiential, physiological, and behavioral responses that trauma-related stimuli. They aresimultaneouslyprovided persist over time as an individual learns first to experience with emotion-regulation tools to cope with trauma-related and tolerate the generation of internal “core affects” [57]) emotions, rather than engage in the avoidance that perpet- and then to learn strategies to modulate these emotions uates PTSD. More specifically, they learn skills to activate within the context of environmental challenges and intern- positive emotions and engage in couple soothing and ally generated goals and cognitions [58]. Conceptual models empathic mutual support that increases distress tolerance that differentiate between the generative and the regulatory [64]. For example, couple soothing exercises help couples aspects of emotional control [12, 58] are consistent with to identify and engage in behaviors to cope with negative data showing that different neural systems mediate the affect by promoting feelings of relaxation and intimacy. relationship between fear-related emotional reactivity and These soothing behaviors can include traditional relaxation emotional inhibition and control [58, 59]. Similarly, the techniques such as deep breathing, positive thinking, or behavioral responses to sudden increases in trauma-related imagining a relaxing place as well as activities that they emotions [60] are distinctly different from the more enjoy doing together such as cooking or exercising. This Perlick et al. Military Medical Research (2017) 4:21 Page 6 of 10

process of teaching couples to decrease emotional avoid- and evaluated in an open trial with seven Iraq and ance while increasing support for disclosing and discussing Afghanistan veterans and their partners and, more traumatic memories and emotions reduces veterans’ recently, in a randomized clinical trial comparing a 12- vulnerability to PTSD while increasing couples’ psycho- session SAT intervention with a 12-session couple-based logical resilience. education condition called PTSD family education (PFE) The couples then participate in 6 disclosure-based [68]. Seventy-six percent of the 57 OEF/OIF/OND exposure sessions in which the veterans are prompted to couples who were randomly assigned to a group were reveal and discuss trauma-related memories and emotions retained through three months of follow-up assessments. with their partners. This disclosure process is intended to Intent-to-treat analysis revealed that both the SAT and the expose the veterans gradually to trauma-related emotions. PFE veteran groups showed significant reductions in self- Couples learn to approach and not avoid the trauma- reported and clinician-rated PTSD during the treatment related problems that have devastated their relationship in period and at 3-months follow-up. However, the veterans the past. Through this conjoint SAT, the veteran has who were randomly assigned to SAT showed significantly multiple trials of exposure to trauma-related memories greater reductions in PTSD than those who were and emotions to habituate to anxiety cues while also randomly assigned to PFE. Specifically, every couple who cognitively processing the trauma in a supportive context. received SAT had a reduction in veteran PTSD within just SAT’s emphasis on disclosure is grounded in findings twelve sessions, which was maintained over a 3-months that returning veterans who speak about their combat follow-up period. Fifteen of the 29 (52%) veterans in SAT trauma to an intimate partner experience decreases in and two out of the 28 (7%) veterans in PFE no longer met posttraumatic stress [65] while simultaneously improv- the DSM-IV-R criteria for PTSD (operationalized as ex- ing their relationship quality [66]. It is important to ceeding a total CAPS score of 45) at 3-months follow-up. emphasize that SAT does not involve exposing the Additional analyses revealed that the veterans’ decreases veteran to the same intensity of trauma-related emotions in fear of intense emotions (emotion generation) and their as prolonged exposure. Instead, SAT is designed to improved emotion-regulation skills partially mediated the permit opportunities for anxiety habituation during relationship between treatment with SAT vs. PFE and treatment while also providing instruction on the reductions in PTSD symptoms (CAPS change score communication, emotion regulation, and anxiety- ĉ =1.03,P = .003). These data indicate that improving management skills that allow the couple to use disclos- emotion regulation is an important element in the ure practices to confront avoidance trauma both when successful treatment of PTSD with SAT [69]. they engage in disclosure work in the last 6 sessions and after the conclusion of treatment. For example, skills Multi-family group for military couples (MFG-MC) training in acceptance allows them to tolerate challen- Although individual couples treatment is often used with ging emotions more effectively as the veteran discloses PTSD, group treatments have the advantage of permitting his or her traumatic experiences. The couple is also coa- participants to learn from each other and can also reduce ched to use their empathic communication skills to stigma. They are also more efficient. Multi-family group identify and discuss their emotional responses to the dis- (MFG) for military couples with trauma associated with closure. For instance, the veteran’s partner is coached to combat stress/exposure and/or mild traumatic brain validate the veteran’s trauma-related emotions and injury (mTBI) is an adaptation of multi-family group treat- encourage him or her to join in a couple-soothing exer- ment, an evidence-based treatment for serious mental cise designed to provide comfort while discussing the illness that uses education, problem-solving skills training emotional challenges of confronting the trauma. Incorp- and support to reduce symptoms and improve functional orating emotion-regulation and communication skills outcomes [47]. Perlick and colleagues adapted the MFG into the disclosure phase allows the couple to process approach to address the needs of post-911 veterans with traumatic memories and emotions in an accepting and mTBI and/or full or sub-syndromal PTSD in an open, supportive dyadic context. feasibility trial [10, 11]. They are currently evaluating this treatment in an ongoing VA-funded multi-site RCT Efficacy of Structured Approach Therapy comparing the benefits of MFG-MC compared to health The initial 12-session manual-based treatment was tested education (HE). in an uncontrolled trial with Vietnam veterans with PTSD The MFG-MC model uses a structured, behavioral and their spouses. Participating veterans showed signifi- approach to provide veterans and their partners with cant reductions in avoidance and numbing symptoms in education and problem-solving instruction as well as addition to significant decreases in their overall PTSD emotion-regulation and communication skills training to scores [9]. Based on these positive findings, the manual improve coping and help couples to reconnect through was modified to meet the needs of post-911 veterans [67] positive behavioral exchanges. MFG-MC consists of three Perlick et al. Military Medical Research (2017) 4:21 Page 7 of 10

sequential components: 1) “joining” in which clinicians The communication skills that are taught in MFG-MC meet with each individual couple for 2 sessions to evaluate (active listening, expressing positive and negative feelings, their ongoing problems and define the treatment goals, 2) making a positive request, requesting a time-out, and nego- a 2-session educational workshop that provides informa- tiating and compromising) are drawn from the BFT manual tion about post-deployment strains and mental health [72] but have been adapted to incorporate emotion- sequelae to all veterans and their partners, and 3) twice- regulation strategies to enhance their effectiveness in this monthly multi-couple group meetings for 6 months (12 cohort. Couples are told that the skills are composed of sessions) that provide a structured format, including out- specific steps that can be difficult to follow when emotions of-session practice, to build problem-solving, emotion- and/or conflict are high and that it is important to practice regulation and communication skills while receiving social emotion-regulation skills to use the skills effectively. For ex- support. The multi-group session’sskillstrainingsessions ample, the communication skill “expressing negative feel- are delivered in three phases. ings” in the BFT manual has been reframed as “expressing In phase I (sessions 1–3), the participants are negative feelings mindfully”.AstaughtinMFG-MC,this introduced to formal problem-solving methods (i.e., skill begins with a preparationstepinwhichtheindividual operationalizing the problem, generating solutions pauses mindfully to examine his/her internal experience non-judgmentally, evaluating the pros and cons of and action urges and to consider the impact of expressing each solution, picking a solution and planning the im- negative feelings on the partner/relationship. The questions plementation), using concrete problems in daily living that are examined during the preparation step include related to PTSD or mTBI (e.g., difficulty remembering “What is the anticipated outcome on the relationship of scheduled appointments, chores, engaging in family expressing negative feelings?”, “Can expressions of negative activities in crowded areas) that are generated by the emotions reinforce our dysfunctional communication pat- participants. Non-affectively loaded problems are se- terns?”,and“Can expressions of negative feelings mask lected initially to facilitate skill acquisition. Group underlying feelings that are more potent contributors to participation is encouraged to foster social support my current relationship distress?” This mindful introspec- and build a working alliance between the group mem- tion serves as one form of emotion regulation. If the bers and the clinicians towards a common goal. Phase individual decides to proceed with the communication, and II (sessions 4–6) teaches skills to facilitate accurate the discussion becomes heated, the partners are instructed recognition, labeling, and regulation of negative emo- to request a time-out to avoid dysregulated, reactive tions that are experienced by the veterans and their responding. When requesting a time-out, the person is partners. In session 4, they members learn mindful- instructed to give a reason, rather than simply storming ness “what” (i.e., observe, describe and participate) out. For example, the person might state that he/she feels and “how” (i.e., non-judgmentally) skills [70]. These unable to proceed constructively, that his/her emotions are skills help the veterans to learn to or relearn to pause taking over and that it will be better to resume at another and self-reflect between processing the external time. Participants are also instructed to give a timeframe stimulus and generating a behavioral response, an im- for resuming the discussion or at least indicate an intention portant foundation of emotion regulation. Session 5 to resume the discussion when “Iamable”.Duringthe focuses on crisis survival or distress-tolerance skills time-out, each partner is encouraged to practice mindful- (distraction, self-soothing and improving the moment) ness and distress-tolerance skills such as distraction, self- and acceptance, whereas session 6 focuses on soothing and acceptance to reach a state of mind and advanced emotion-regulation skills that might be affective stability that would permit a constructive discus- implemented once the acute distress has passed as sion. These modest additions to the “expressing a negative well as skills to prevent or reduce reactivity to nega- feeling” and “time-out” skills that are taught in BFT take tive emotions in the future, including maintaining into account and acknowledge the potential reactions of healthy eating habits, establishing an exercise routine the other person and, thus, are practicing relational and practicing good sleep hygiene. Phase III (sessions mindfulness. 7–11) builds on the skills that were learned in phases I and II to increase the awareness of dysfunctional Efficacy of MFG-MC communication patterns and substitute more effective The aforementioned RCT is ongoing; however, the initial ways of interacting to increase intimacy, marital/rela- open trial pilot study with 11 veterans and 14 partners tionship satisfaction and the ability to negotiate and found that the intervention was effective in reducing vet- effectively solve complex interpersonal problems. It erans’ PTSD symptoms (pre–posttreatment Cohen’s begins with a discussion of “relational mindfulness” d = 0.82), anger management (d = 0.61), instrumental and [71], which is defined as being mindful of one’spart- subjective social support (d = 0.85) and vocational function- ner’saswellasofone’s own thoughts and feelings. ing (d = 1.03). Participation in MFG-MC was also Perlick et al. Military Medical Research (2017) 4:21 Page 8 of 10

associated with reduced family burden (d =1.03)and research should also highlight if specific PTSD symptoms increased family empowerment (d = 1.66) [11]. Feedback are especially responsive to emotion-regulation strategies elicited from the participants in the final session of each or might be differentially responsive to specific ER group also supported the value of incorporating skills train- strategies. Studies of treatment matching might help to ing in ER and communication skills training. As one determine whether couples who are dealing with dysregu- veteran stated, “… a lot of this stuff I did utilize, like time- lated behavior might benefit more from interventions that outs and stuff … There were times I wanted to fly off the incorporate emotional-regulation skills training, whereas handle. I had to remember some of the things you all veterans who are struggling more with troublesome taught me”.Inthewordsofapartner,“We needed to know thoughts (such as those associated with moral injury [74]) how … to learn to communicate, effective communication, might benefit from more cognitive strategies. Most studies notwhatwethoughtcommunicationis… but really under- to date have focused on PTSD symptom outcomes and standing what it means to have effective communication”. relationship satisfaction. Future studies might benefit from the inclusion of a broader range of outcomes, specifically Conclusions psychosocial re-integration, functional and/or vocational Limitations and future directions outcomes, to address the important question of whether If they are fortunate, PTSD survivors have the opportun- improvement in symptoms and relationship satisfaction ity to recover while living and interacting with important facilitates veterans’ recovery within the community. Future people in their life. The difficulties in the lives of these studies of combat veterans should also examine traumatic survivors and their loved ones often result from the im- events preceding military service, as the impact of pact of PTSD symptoms and comorbidities on marital combat-related trauma might vary in relation to the pres- and family relationships, highlighting the potential im- ence of prior trauma and the veteran’s adaptation. Finally, portance of conjoint treatments. Tremendous progress replication studies are needed. has been made in this treatment approach in the last 30 years, moving from simple clinical observations and Abbreviations BFT: Behavioral family therapy; CBCT: Cognitive behavioral conjoint therapy; speculation to rigorously conducted, theoretically rich EFT: Emotionally focused therapy; ET: Exposure therapy; HE: Health education; experimental trials of innovative couples interventions. IBCT: Integrative behavioral couple therapy; MFG: Multifamily group; MFG- The initial results of research on both SAT and MFG as MC: Multifamily group for military couples; mTBI: Mild traumatic brain injury; OEF/OIF/OND: Operation Enduring Freedom/Operation Iraqi Freedom/ well as the findings of research on CBCT for PTSD sug- Operation New Dawn; PFE: PTSD family education; PTSD: Post-traumatic stress gest that embedding PTSD treatment within a relational disorder; RCT: Randomized controlled trial; REACH: Reaching Out to Educate context might be an effective way to reduce PTSD while and Assist Caring, Healthy Families; SAT: Structured approach therapy; SMI: Serious mental illness; VA: Veterans affairs also enhancing the couple’s or family’s ability to support ’ veterans recovery. In these approaches, relatives learn to Acknowledgements help veterans to manage the powerful trauma-related The authors would like to acknowledge the invaluable contribution made by emotions that impact their relationships while also the veterans and partners who participated in the reviewed research. acquiring the communication and problem-solving skills Funding to cope with the stresses and problems in life. Not applicable. Embedding behavioral treatments that provide emotion- regulation skills in a couples therapy (SAT) or multi- Availability of data and materials couple group (MFG-MC) context has the potential to Not applicable. yield immediate post-treatment reductions in PTSD ’ Authors’ contributions while also having the promise of improving the family s DAP developed the multifamily group treatment (MFG) adaptation for post- capacity to support long-term PTSD recovery. In sup- 911 veterans with traumatic stress and their partners and is responsible for port of this thesis, a recent review of the role of negative the conceptualization of the paper. She wrote the sections on multi-family group and the importance of incorporating emotion regulation treatment affect in the development of PTSD across multiple strategies for this cohort of veterans. She also took responsibility for the trauma populations argued that negative affect disrupts overall organization and editing of the paper. FJS developed Structured the cognitive processes that are needed to participate in Approach Therapy (SAT) treatment and primarily wrote the review section on this treatment, as well as supplying material on models of emotion cognitive behavioral therapies fully and recommended regulation. JBC assisted FJS in writing the section on SAT. DS assisted DAP in ways to incorporate regulating negative affect prior to writing the details of the MFG-post 911-TS treatment structure. SG reviewed beginning cognitive behavioral therapy [73]. pertinent literature for the main body of the article and drafted summaries for the other authors to use for their review. AVL and MMS provided There are still important research questions to be ad- expertise in veteran cohorts experiencing emotion dysregulation and PTSD dressed. They include determining if PTSD couple treat- symptomatology. SMG co-developed Behavioral Family Therapy. She ments that incorporate emotion-regulations skills training primarily contributed to the section on BFT as well as the review of early interventions developed for veterans with PTSD and their families that confer equal benefits as cognitive-behavioral approaches preceded the development of the MFG and SAT. All authors read and such as those developed by Monson et al. [50]. Additional approved the final manuscript. Perlick et al. Military Medical Research (2017) 4:21 Page 9 of 10

Authors’ information 7. Monson CM, Taft CT, Fredman SJ. Military-related PTSD and intimate DAP is the Associate Director for Family Intervention Research for the VISN 2 relationships: From description to theory-driven research and intervention South MIRECC at the James J. Peters VA Medical Center. She is also an development. Clin Psychol Rev. 2009;29(8):707–14. Associate Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai. 8. Gross JJ, Barrett LF. Emotion generation and emotion regulation: One or FJS is a Professor of Clinical Psychiatry at the Tulane University Medical two depends on your point of view. Emot Rev. 2011;3(1):8–16. Center. He is also the Team Leader of the Family Mental Health Program for 9. Sautter FJ, Glynn SM, Thompson KE, Franklin L, Han X. A couple-based the Southeast Louisiana Veterans Health Care System. approach to the reduction of PTSD avoidance symptoms: Preliminary JBC is an Assistant Professor in the Department of Psychiatry and Behavioral findings. J Marital Fam Ther. 2009;35:343–9. Sciences at the Tulane University Medical Center. 10. Perlick DA, Straits-Tröster K, Dyck DG, Norell DM, Strauss JL, Henderson C, et DS is the Project Director for DAP’s research at the James J. Peters VA al. Multifamily group treatment for veterans with traumatic brain injury. Prof Medical Center and Mount Sinai. Psychol Res Pr. 2011;42(1):70. SG is the Clinical Research Coordinator for DAP’s research at the James J. 11. Perlick DA, Straits-Troster K, Strauss JL, Norell D, Tupler LA, Levine B, et al. Peters VA Medical Center. Implementation of multifamily group treatment for veterans with traumatic AVL is the Scientific Director for Well-being Literacy via Multimedia Education brain injury. Psychiatr Serv. 2013;64(6):534–40. and Psychosocial Research at the Washington DC VA Medical Center. He is 12. Price J, Manson C, Callahan K, Rodriguez J. The role of emotional also an Associate Professor of Rehabilitation Medicine at the Georgetown functioning in military-related PTSD and its treatment. J Anxiety Disord. University Medical Center. 2006;20:661–74. MMS is the Program Director for Well-being Literacy via Multimedia Education 13. Klemanski DH, Mennin DS, Borelli JL, et al. Emotion-related regulatory and Psychosocial Research at the Washington DC VA Medical Center. She is also difficulties contribute to negative psychological outcomes in active-duty an Assistant Professor of Rehabilitation Medicine at the Georgetown University Iraq war soldiers with and without posttraumatic stress disorder. Depress Medical Center. Anxiety. 2012;29(7):621–8. SMG is the National Program Manager for Family Services Training within the 14. Monson CM, Price JL, Rodriguez BF, Ripley MP, Warner RA. Emotional VA Marital and Family Counseling Team, Office of Patient Care Services. She deficits in military-related PTSD: An investigation of content and process is also a Clinical Research Psychologist in the Department of Psychiatry and disturbances. J Trauma Stress. 2004;17(3):275–9. Biobehavioral Sciences at the University of California – Los Angeles. 15. Badour CL, Feldner MT. Trauma-related reactivity and regulation of emotion: Associations with posttraumatic stress symptoms. J Behav Ther Exp Competing interests Psychiatry. 2013;44(1):69–76. The authors declare that they have no competing interests. 16. Ehring T, Quack D. Emotion regulation difficulties in trauma survivors: The role of trauma type and PTSD symptom severity. Behav Ther. 2010;41(4):587–98. Consent for publication 17. Kulkarni M, Porter KE, Rauch SA. Anger, dissociation, and PTSD among male Not applicable. veterans entering into PTSD treatment. J Anxiety Disord. 2012;26(2):271–8. 18. Elbogen EB, Wagner HR, Fuller SR, Calhoun PS, Kinneer PM, Beckham JC. Ethics approval and consent to participate Correlates of anger and hostility in Iraq and Afghanistan war veterans. Am J Not applicable. Psychiatry. 2010;167(9):1051–8. 19. Novaco RW, Chemtob CM. Anger and combat-related posttraumatic stress Author details disorder. J Trauma Stress. 2002;15(2):123–32. 1JJPeters Department of Veterans Affairs Medical Center and VISN2 South 20. Allen ES, Rhoades GK, Stanley SM, Markman HJ. Hitting home: Relationships Mental Illness Research, Education and Clinical Center, 130 West Kingsbridge between recent deployment, posttraumatic stress symptoms, and marital Rd, Bronx, NY 10468, USA. 2Department of Psychiatry, Icahn School of functioning for Army couples. J Fam Psychol. 2010;24(3):280. Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, USA. 21. Erbes CR, Meis LA, Polusny MA, Compton JS. Couple adjustment and 3Southeast Louisiana Veterans Health Care System, 1601 Perdido St, New posttraumatic stress disorder symptoms in National Guard veterans of the Orleans, LA 70112, USA. 4Tulane University School of Medicine, 1430 Tulane Iraq war. J Fam Psychol. 2011;25(4):479. Ave, New Orleans, LA 70112, USA. 5Research and Development, Washington 22. Sherman MD, Perlick DA, Straits-Tröster K. Adapting the multifamily group DC VA Medical Center, 50 Irving St NW, Washington, DC 20422, USA. model for treating veterans with posttraumatic stress disorder. Psychol Serv. 6Georgetown University Medical Center, 3800 Reservoir Rd NW, Washington, 2012;9(4):349. DC 20007, USA. 7VA Greater Los Angeles Healthcare System, 11301 Wilshire 23. Carroll EM, Rueger DB, Foy DW, Donahoe CP. 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